Scazi, Roseann r 1
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NEW YORK STATE DEPARTMENT OF HEALTH Bur;C�i . Transit Permit
Vital Records Section f
Name First M le (Lost Sex
J�d S g-h3-n/„J J fO7L,if J c-i?.i♦ 1 i---6-iitrale
>= Date of Death / / I Age I If Veteran of U.S.Armed Forces, J
!0 / /3// (o I Co or I orDates AIVa"
P of Death /^ Hospita, Institutionr
PtCity own or Village e,Li /�o-to eet Address C EP,,�_S F8 c-S
® anner of Death aNatural Cause 0 Accident n Homicide D Suicide riUndetermined �Pending
Circumstances Investigation
tj lij Medical Certifier Name CI �` � I %Lk.\ Title (: ,1„_ , (�h y Si C l
on
Address f K t 1'
I00 Par IL 3f 6L is FaI S, 1W I D1
Death Certificate Filed I District Number 56,` I Register Number ,Li
(City, own or Village G Ger S / ai_'(..s I 1 1Burial Date Cemetery or Crematory��> V
/v I Y�l (.J ) C--.)
❑Entombment Address
>LCremation a Uel&v•--- Q U,, icl3+Q L JZ cpd y
Date ' Place Removed ` /�7
uRemoval I and/or Held
and/or Address
Hold
al
10 Date Point of
Q Transportation I Shipment
a by Common Destination
Carrier i
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home E -�i L c \ 0 c \� C .11 .?C'
Address
kx LCSaNte. ��- CL , ' ) 1 , K\ tiZ`cct
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rz
IJI
4iPermission is hereby granted to dispose of the human reynains d cribed a ove as indi•meted.
0Date Issued f 4 Wit{ Registrar of Vital Statistics ` � s
I (signature)
District Number�� Place Fe,_ /
-77/
I certify that the remains of the decedent identified above were disposed of in accordance ith this permit on:
p o Place of Disposition
its Date of Disposition / l�l-�` fut./J..1 CchTatOrw--,
Z (address)
ILI
111
(section) A (lot number)( (grave number)
i Name of Sexton or Person in Charge of Premises .,
(lot
Jl,n(
z ( lease print)
t Signature 0 Title <t elltrAt,
(over)
DOH-1555 (02/2004)