Silva, Carol Wit
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Ili Name First Middle Last Sex
Coro\ r\A Si 1vo, F
Date of Death Age // __ I If Veteran of U.S. Armed Forces,
OL 11% 1201L.4 (.o 1 j War or Dates N R."
i* Place of Death Hospital, Institution or
City,gartiosr Village Queersbc.:•r Street Address �e�r, �—o.n e
Manner of DeathL,Ad'Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
, 11 ; 0 '60 CO M--\"
Address
1 t \ Cc 4 P\Doza A)� \�bc-)
Death Certificate Filed District Number Re/i 1er Number
`<! City wvr o or Village QvP S ,r•-i ' 7
Date 1 Cemetery or Crematory
❑Burial 0�-1 12- 1 a.01 U2 -; ne_ U +Cu° Crl'- a4oi--/
Address
Cremation QUc.\ v '(40-C1 Q oeev O c t Ny \ZD(f.
I Date - j Place Removed
Z❑Removal and/or Held
1:29 and/or Address
'- Hold
Q Date Point of
thQ Transportation, i Shipment
fl by Common Destination -
Carrier
Disinterment Date I Cemetery Address
Reinterment I Date Cemetery Address
'<> Permit Issued to _ ) / Registration Number
` ' Name of Funeral Home __ . R rot .;�,47tiu ,. /7i� I t Oil 3Q
>: Address ,
it Lrk ) IU- S; ( u ,,isCSur 1U . /2, y
iti Name of Funeral F Making Disposition or to Whom d 1
Remains are Shipped, If Other than Above
Address -
Permission is hereby granted to dispose of the human remains described above as indicated.
ii:igDate Issued:D-1 L al -( -, Registrar of Vital Statistics----—, Q nEfl,t..,,,
_ (signature)
IN ,
`i District Number 6c) Place 1 D csu) 0 L._-e.-e_4-,aL
I certify that the remains of the decedent identified above were disposed of in accord nce ith this permit on:
F j�
W Date of Disposition 21/4 f/t, Place of Disposition at Vf Cr e dr_
2 (address)
LLI
f)
CC (section) (Igt number (grave number)
2 Name of Sexton or Person-in Charg f Premises • t`jri,I JO+wit
Z (please print)
Signaturea - , Title f ete
- (over)
DOH-1555 (9/98)