Bresadola, Rose NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiiiiiii Name First z, Middle Last Sex
D sE- L)/1 J/D OLA F
iiil Date of De th' Age If Veteran of U.S. Armed Forces,
( p/ 9 War or Dates N d
Place o eath � Hospital, Institution or
City, Town or Village L /e6= / 4 d Jo Street Address Li///L EM/ Cn cy C' ,
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
iii ivieaicai Certifier Name Title
/ A ess
Nil "J/tL t"� C'zc�i !7 z. C-4 /`�L4/cr c/49 /l/
DeathCertificate ile / District Number ' Register Number
City, Town or Village�../c P64 ep i,.5'‘,.s`"
Date Cemetery or Crematory
❑Burial �1 J� /9. - t/ V/,L CA1--=`/ %4A-7
Addr ss _
:::::14 Cremation OIL�-/S/-1 /—_
/f 4 of A/ )/
Date Place Removed
U❑Removal and/or Held
••• and/or Address
1.7 Hold
Date Point of •
y❑Transportation Shipment
a by Common Destination
Carrier •
:: 0 Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
ioi Permit Issued to Registration Number
Name of Funeral Home i• O. Clark, ; nu, IP C 3 /
'' Address ;7 Saranac Ave.
iik lake Placid, N.Y,1280
�`ii Name of Funeral Firm Making Disposition or to Whom
Com Remains are Shipped, If Other than Above
Address
W
gilii Permission is hereby granted to dispose of the human remains described above as indicated.
,---
Date Issued // /..r/ S-- Registrar of Vital Statistics _A \u a A A _ 5. 1 t1nctu L
(signature) ^I
iiiiiiiii District Number l_S'Z,' Place L /C /�C,C�C/ /y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition V-1b`/Place of Disposition/'iI / iEa) C/? v1/7/c1�/rLJ/�
,+, '*: (address)
W
Cl)
CA (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises EDhJ9J{D/ ,/f/ 7 ?'i9&
g (please print) t
I4 Signature Title �R.E/!7/9r/ry !7//
DOH-1555 (10/89) p. 1 of 2 VS-61