Tarentelli, Kathleen 4 s
it 55
NEW YORK STATE DEPARTMENT OF HEALTH p
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex r-
V cA% lee�n Taren-1t11 .
Date of Death Age U I If Veteran of U.S. Armed Forces,
O$ O 2
I 1 .01 l0 t 5 War or Dates N 1 A
Place of Death Hospital, Institution or
Town or Village Glens Fq1\S Street Address 11f1 e. P► Y1e.SN
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined 0 Pending
Ui Circumstances Investigation
W Medical Certifier Name Title
t Mel iSSa D ehea M O
r Address
°1 Cct v el RoQi.C1 Ouee S\o Cy API 1Zgvy
Death Certificate Filed District Nurtiber Register Number
CCitv)Town or Village G't ens FQ A I 5 60 / 3 9l 1
❑Burial 1 Date O Cemetery or Crematory
D� en I 8 )3 aol h Tine \!i cu.) Cn Ccra'+orf
`rt.. ' rn, t i Address
(Cremation e PY\Sbvr r N
k Date Place Removed
g❑Removal and/or Held
and/or Address
Hold
0 1 Date Point of
t0 Transportation Shipment
by Common Destination
Carrier
E Date Cemetery Address
Li Disinterment
1 Reinterment l Date Cemetery Address
{
Permit Issued to Registration Number
Name of Funeral Home Bo,Y)er F)nero1 Horne o i 1 ao
Address
Yt Levee:Levee:of e- e. S-. ®ucenSbvey, NY 12. Soy
. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
i
'Ili
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 8/3 1 i 61 Registrar of Vital Statistics ln> ,�
(signature)
District Number 56b i Place 6 (Q,\A.c Et t k S, y
Z I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iti Ui Date of Disposition $/61/6 Place of Disposition f rHU,�
(address)
ill
(section) 4 (lot number) c (grave number)
Name of Sexton or Person in Charge of Pr ises v� St
Z marl tr.,
lease print)
lAi Signature d Title Chi (,
(over)
DOH-1555 (02/2004)