Dideo, Valerie NEW YORK STATE DEPARTMENT OF HEALTH' * 44 172-
Vital Records Section Burial - Transit Permit
Name First Mi dle La Sex
�4z�',� 4; c-
Date of Death / Age If Vetetan of U.S, Armed Forces,
iii, r / /a Di X War or Dates
)• Place of Death / Hospital, Institution or
.Z City, Town o ilia L o^ Street Address 14 li¢i M li- AV el Ka—
pW Manner of Dea Natural Cause. 0 Accident 0 Homicide 0 Suicide a Undetermined 0 Pending
LLI Circumstances Investigation
W Medical Certifier Name Title
.o VI\ /eJexo , . rho
Address_o ;Ie.,. . -- 17el, yit A % / fs°r
Death . ate Filed district :mber RegRegister Number
-
Cit • Tow or Village �fl/'; 't c 53
Date Cemete or Crematory
. Burial / '/7/'a' K „, ,e_vd_-.� C.-.ccMti4-br
Address
' Cremation 64,le-e„ 5..6,r 'J�c-,.. `T�i4
Date � / Place Removed
g0 Removal and/or Held
- and/or Address
V) Hold •
0 Date Point of
0 Transportation Shipment
Q by Common Destination
Carrier •
Disinterment Date Cemetery Address.
Reinterment Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home -n 5M r t ��-.'le_t_ ^c- .4---- _ Da`-�'r Y
Address �� y
7 .PrAA A.. Avt/ c- �/'-•' /LI / ) K)) -
i> > Name of Funeral Firm Making Disposition or to Whom
�' Remains are Shipped, If Other than Above
3 Address
114
Permission Is hereby/granted to dispose of the human r= - • :scribed ov- -�-• •icated.
5 Date Issued ]a76'/r
<> Registrar of ViCal Statistics Age)
, •,a ire) Y
District Number 5-C3 Place o/� � �/ O�, / r."(,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- ,. ``'' 9
w Date of Disposition I2 I l 118 Place of Disposition V., L_1 (rvy-c O ...
E (address)
uw
( ,
Cr (section) n Slot number)/- (grave number)
O Name of Sexton or Person in Charge of Premises ..30v1O K
O.
(please print)
W Signature 66•/ Title (Mena_
IJ/
DOH-1555 (10/89) p..1 of 2 VS•6)