Bazinet, Genevieve NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
ffli Name First A M le Last Se
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D of Death Age _l If Veteran of U.S.Armed Forces,
tti1 r �� 1:.: . C� War or Dates
Z Place of Death Hospital, Institution
u„# City Town or Village y� ; j Street Address41 &At 11(,0 ,t4jc -44,1) 7(�
W Manner of Death r1 Natural Cause Accident Homicide Suicide Undetermined Pending
u" Circumstances Investigation
W Medical Certifier Name n Title
Address M1Lt,1 i%(. ,i, l ,>7 0 9 Ltd '(i '��i
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Death Certificate Filed District Number 1.. Register Number
City,Town or Village ��uh ' L) 6LC i �" 9.
Date Cem,ry or Crgg�atQqry
urial l `a /� / J I {yam J
Ly 1" . YI�(�LC'
Cremation Addrenaka ,
vu.6. uw 4)2 1..9u
z Date
0, ❑ Removal and/or Held
i ' and/or Hold :::::
Address
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O':>.:..:.:. ..:. ..... .:::,.. ..........
O. Date Point of
v)`, ❑Transportation by
p Shipment
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Destination
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
le Permit Issued to f� Registration Number
,,..:Name of Funeral Firm h • ! Va..M { irr i't 4 • D:.:Jq t1�
�J 9n
Address 61 Pauc16-tui- , / tit 1� (...:. .../: r ....... ....... ..
:' Name of Funeral Firm Making Disposition or to Whom
j Remains are Shipped, If Other than Above
g: Address
a;
Permission is hereby granted to dispose of the hum remains described
_ above as indicated.
iiiiil Date Issued 19'`ib `9I Registrar of Vital Statistics ,i(,2(, CG2,�L
4,04
ezw-
��II,JJn� (signature)
District Number ` ' Place ,.a.,. .„
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Queensbury, NY
Z> Date of Disposition 4/16/92 Place of Disposition St,, Alphonsus Cemetery, Corner Pine St. & Luzerne Rd.
W (address)
w Section II, Row G, 26 10A
Ncc' (section) (lot number) (grave number)
caName of Sexton or Person in har a of Premises Joseph A. Falletta
Z ',r i (please print)
Lu Signature7 j Title Pastor
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DOH-1555 (10/89) p. 1 of 2 VS-61