Ramos, Ricci NEW YORK STATE DEPARTMENT OF HEALTH itZ11)
' Vital Records Section Burial - Transit Permit
Name FirstRicci Middle Paul Lasamos Sex Male
Dat8 jfl pi5bt,8 Age63 years If Veteran of U.S. Arr ens d Earce.s73
War or Dates
1-. P of Deat Hospital, Institution or
W crown or� X Wilton Street Address 100 Gordon Lane#226
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
I Circumstances Investigation
W Medical Certifier Na a Title
Susan Hayes Masa Coroner
Ada44rcMaster Steet, Ballston Spa, NY 12020
erti#ic �Qd ,D)sri rn.bcr ,; ,Registter, Number,
'.::.. OW, own or i ag } :Wilton ` : 18
❑Burial f
Date Cemc,+ • —r'ramatn v r
3/4 3 1 ) e n,E ti 1 Ew c:.i��m(}T -i
❑Entombment AddrePc
[Cremation Qv,ee S 1/- ,"ui , N l( ) 2 6 01
Date Place Removed '
t Removal' and/or Held"
and/or
Address
t Hold
Ogro
3 Date Point of
tL Transportation Shipment
0 by Common Destination
Carrier -
-' Date
DisintermentCemetery Address " .
Reinterment Date Cemetery Address
_.
Permit Issued to Registration Number
Name of Funeral Home Tv P7SbrJ F0 W3(, HHb
Address
(b r tAv, Ave/Jut 5047064 SPi`�--N&s (ZCI.
Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
CC
Permission is hereby granted to dispose of the human remains described above ars`indicated.
03/21/2018 Date Issued Registrar of Vital Statistics illi'`,,/`/ /signatur )
iiig District Number 4569 Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition Vole$ Place of Disposition -C,tL,./ (M-I+'
(address)
ILI
(section) A (lot number) r (grave number)
CIName of Sexton or Person in Charge of/Premises ` fir. J
( ease print)
Signature L✓l , Title ftki►t1
(over)
DOH-1555(02/2004)