Iannaccone, James •
NEW YORK STATE DEPARTMENT OF HEALTH It 2
Vital Records Section Burial - Transit Permit
Name Fjst Middle Last Sex
Date of Death / Age If Veteran of U.S. Armed Forces,
6o/6c3/,26i( War or Dates
j- Place of Death ` Hospital, Institution or ,� f
Z City, Town or Village L. .- t /a` /QWlil Street Address f,(.l M-&-jli I i f / f7/(4)L
Ww�Manner of Death ']Natural Cause 0 Accident 0 Homicide 0 Suicide riUndetermined Pending
UJ Circumstances Investigation
Ill Medical Certifier _Name Title
0 g-/e,,£i--16/ SAL/EL 1v1 6
Address
0 ox rIP/e ketiA-r6/ � ( , ty, to93
Death Certificate Filed L ,.,i District Number 5 Register Number
City, Town or Village 1? L i t1;114 Io
❑Burial Date ���f Cemetery or Crematory _ �r
['Entombment `
���` PILL F/fU 1( CY L ivetq-1//'
Ad(Ts
[}Cremation V GC- S 6 1.1 fay N. a_c I 4
Date Place Removed
Z Removal and/or Held
0❑and/or
F Address
CA
Date Point of
i2 Transportation❑ p Shipment
Et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home lf` 1 stCe az L kL1_,1 fDive Ai-116 co
Address
pt4i(vei,r S r: pl, tx,.AL i-i-Its i )1 /.2 'f0
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
tr.
til
CL
Permission is hereby granted to dispose of the human mains described j
aboveov as indicated.
Date Issued Registrar of Vital Statistics �bite? �'G' [
(signature)
District Number /Sc� Place , ii b. ,
I certify that the remains of the decedent identifiedid' above were disposed of in accordance with this permit on:
2
UI Date of Disposition b-itf-i( Place of Disposition Pi„u VI aJ C elo`i„�
t (address)
CC (section) (lot number) r^'` (grave number)
Name of Sexton or Pe on in Charge Premises 1r'e•st �.A 41
(ple se'print)
tik
Signature � " (fj'!�
g Title A t 0P-
(over)
DOH-1555 (02/2004)