Anselmo, Todd NEW YORK STATE DEPARTMENT OF HEAL H v10-17
Vital Records Section Burial - Transit Permit
Name first Middle Last Sex
c C1c� A n..t_-_,I rn D Malt,
> Date of Death Age If Veteran of U.S. Armed Forces,
11 .-a- ,9,E- D,Q I t 45 War or Dates 00
Place of Death Hospital, Institutio or
City{Town r Village)cNN Street Address 1 NA yt.Alb, RC
to Manner of Death❑Natural Cause 0Accident 0Homicide 0 Suicide Undetermined �Pending
tl Circumstances Investigation
tu Medical Certifier Name Title
l TYLn l c i 3- k ut,,_ ec,„- ,y�r-
Address
.13(,115-t-L)n S c) N
ipii Death Certificate Filed District Number Register Number
City,Town or Village `1S�7y 1
!ii':'❑Burial Date / CRetery or Crematory
❑Entombment �e'b 3 a 0 L S i 1 ne. d ill P,1.0 CA"-C4ThA k>
Address •
>> ®,Cremation l,L.C-C,nc,, i
Date Place Removed
3 El❑Removal and/or Held
and/or Address
0 Hold
is
0 Date Point of
to Li Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Mi
0 Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home 4� Ha•,� ( 4 O r yt j t 1►I L. 6 LOB l
Address
iii
c)f C h i,t,► c St- 1 ck_..K LA_ Ze_4--rn, Ny/ 12 3 1-(0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
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"`: Permission is hereby granted to dispose of the human describ d above as indicated.
giil Date Issued c, \�3 Registrar of Vital Statisticst; Q G
kaa\
(signature)
District Number Place �y
I certify that the remains of the decedent identi led above were disposed of in accordance with this permit on:
t
tij Date of Disposition 7,116 Ili Place of Disposition -'' tj..f & ,....,
(address)
III
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of P mises f�"fit i 1
( lease print)
44
Signature Title tekerirti711.
• (over)
DOH-1555 (02/2004)