Savarie, Florence NEW YORK STATE DEPARTMENT OF HEALTH 2 i7Pie
Vital Records Section Burial - Transit rmit
Nam,.9.1 First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
/0 --7- ( Lp ` O(p War or,Dates /''p
I- Place of Death r Hospital, Institution or
CityILI ow or Village U O A'IS j t&r- Street Address A rt ,rt nd& ft �l',
Manner of Death n Natural Cause ❑A cident 0 Homicide Suicide Undetermined Pefiding
I 4� Circumstances Investigation
w Medical Certifier Namg, Title
O . ac . I- i-I-7M 5nn Mi
iJ o r Addres
. �e,C—iLi
NY
Death C rtificate File District Nu, s r Regist 0umber
ws City, o or Village jpk h S VI U ei 0
i' El Burial Date I cemetery r Crematory i
❑Entombment l 0--' ( + j (Q l iv V 1 e t Cie_, r� i
Address ri
[ remation Q GLQ4.4ASiOIA.ry !'Af
Date Place Rerfioved
Z ❑Removal and/or Held
... and/or Address
k:HHold
Cl)
O Date Point of
05 ElTransportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Li Reinterment Date Cemetery Address
Permit Issued to �-- Registration Number
Name of Funeral Home f�,� t 'V, t--i.t ,tr-Li( 1 -c)no e D 1(qw
Address
3 -1 SkrA P, :Q. 50 1 nci li.i Lave fr/ ia 4-2
<a Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
'„ Address
CC
til
' ` Permission is hereby granted to dispose of the human emains described above as in 'cated.
Date Issued I'D\ 11 lip Registrar of Vital Statistics 41t,
(signature)
<-----_
District Number Place /O DJ' d 1 03I01,c
t--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI
Date of Disposition PiaI j, Place of Disposition nt\114-4J 61�0 droi,
(address)
LtiE
Mt
Cr (section) f/ (lot number) (grave number)
Name of Sexton or Person in Charge f Premises �Gs r ��"�
2la ? (ease print)
Signature el Title ip.�
9
(over)
DOH-1555 (02/2004)