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Martino, Olga NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, �� Z C Z O C\(p War or Dates /U p •• Place of Death Hasnita+,FnstttieN or for Village SCa Oc Street Address �-�'©� CGdcf S Manner of Death Dlatural Cause Accident Homicide Suicide Undetermined Pending Uj Circumstances Investigation Medical Certifier Name 0Title p Address n� k<<etDiltrict Death Certificate Filed Number Z�S Register Number City, Town orb "e a Cemetery or Cremat 0 []Burial Date o S�ti Zo A� V;�w �reh�. 0: ❑Entombment Address nn < ; [�remation Q ve e�s� U r I ` Date Place Remov d `z❑Removal and/or Held _. 0 and/or Address =` Hold Date Point of ❑Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Q Reinterment Date Cemetery Address Permit Issued to `3 Registration Number Name of Funeral Home 5 5�u �v"\er6\ C`or►•\L Address Name of Funeral Firm Making Disposition or to Wholm Remains are Shipped, If Other than Above Address I I Permission is hereby granted to dispose of the human rem i s descrabove as indicated. Date Issued 0 1 b Registrar of Vital Statistics (signature) District Number Place � I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LU p p ��%� ll r�Cu� L`��vvz iAlw / Date of Disposition Z!?ZD Place of Disposition (address) (section) (lot number) (grave number) Name of Sexton o rs In Char a of Premises �+ 'n lease print) ase print (pint) NO- Signature Title (over) C) Cog DOH-1555 (02/2004) Public Health Law Sec. 4145(2b) 013750 Receipt Human remains of delivered on w, , 20, Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#