Tessino, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last • SA__
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: -Date of both Age ; If Veteran of U.S. Armed Forces,_I i - 2Cz; -J- 01 (-7 --/ E i War or Dates Ai 0
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.1-ii Place of Death I Hospital, Institution or 0._ € -e-,-. A .
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a City,tf-74 or Village I Street Address _,Q cr-1.......-k-- .. --y---.0
Manner of Death Li jrn Natural Cause U Accident E Homicide E Suicide El Undetermined 17 Pending
ILI "-ICircumstances L*4 InVeStgation
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tu Medical Certifier Name . - Title
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A ifgss 113
i -
Death Certificate Filed ,i District Number I Register Number
;City,Town or Village i 4/5 Go 2. I
Ci Burial 1 Date i Cemetery or Crematory -
i19 ' ''''' `)---'-•--J __/_zL..e, ,Ax-z-4-0____
0 E ritornbment i Address
@Cremation ' "?..: 1.. Q.....,-,_„-Li..-._ R._ r•Ks. Q--,-'---Q--,------Q-)tr--Th)- &A
,
Date i Place Removed
g.-I Removal and/or Held ,
g ----'and/or I Address
Hold I
Date 1 Point of
Transportation ! Shipment
El by Common Destination
ii • Carrier
Date Cemetery Address
F-1 Disinterment
—
r—i .- Date Cemetery Address
Li Reinterment
Permit Issued to Registration Number
Name at Funeral Home 1 ---
Address
Name of Funeral Firm Making Disposition or to Whom -
Remains are Shipped, If Other than Above (-'-‘ (5 ti----1--e--e-- . t-- Lice--------k. ken----c___
Address .—
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...
13.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /0,71//? Registrar of Vital Statistics 4frilv2, 41
(signature)
District Number (../S-(49 2, Place 71 t-P) 0 t 470,C e ci
1... I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Lti Date of Disposition ILI 29 11,7_ Place of Disposition
(address)
lit
41
l'scton) h 4(iptnurnber)c (grave number)
tk Name of Sexton or Person in Chargei of Pre es
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44/1 soul,nnnt)
.44 Signature Title. itterh0P--
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(over)
DOH-1555 (02/2004)