Rituno, Loretta NEW YORK STATE DEPARTMENT OF HEALT7<i ` 1 �10
Vital Records Section Burial - Transit Permit
Name, First Middle La t Sex
1-or e ck, 7oc- K 1 -1-- i t.vt b re vpw.fe
Date of Death 2v . ?/ Age — If Veteran of Armed Forces,
1 Z - b6-- U.S.5 War or Dates Nia
Place of Death Hospital, Institution or /
City, Town or Village 4 4.,attP.c�& 5-e Street Address � 4"e3 51)
Manner of Deatha Natural Cause El Accident Homicide 0 Suicide Undetermined Pending
tki Circumstances Investigation
W Medical Certifier Name .Title
41 1 0� L - `Tv ckci 010
Address C N
SI rat_ r(C 5 f -4- ad ,5e ,Z
Death Certificate Filed District Number Register Number
City, Town or Village sat,.r� s Lj 5'oj c
` ❑Burial D::es
Cemetery or Cre ptory )
[]Entombment �� I1 for V 1 �� C�✓`eAn.4-6, y
As
y►_I Cremation
Date Place Removed
Z Removal 1 and/or Held
2 ❑and/or Address
H Hold
to
O Date Point of
enCL L---
Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address .
N, LiPermit Issued to Registration Ntrter
Name of Funeral Home CO-771 Q 5 to ru.,t,,,,ap�,l e 0 C) 3
Address F
ie X-L,L(2- %Gics&I-e.) 4 54. 1W
Name of Funeral Firm Making DispositionJr to Whom
• Remains are Shipped, If Other than Above
2 Address
C
Ul
tl Permission is hereby granted to dispose of the human remainsdesCribed above as indicated.,
Date Issued I 2---8 — / 6 Registrar of Vital Statistics �' ' `--,�.,_' .p11 ir
_��\\ (signature)
iEii District Number u S V( Place i' �, p� C.,'•..._ p ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i Ili Date of Disposition (t i 1 116 Place of Disposition i 4 Crk �yc-✓ n , r.�-
2 (address)
ILL[
til
re (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Pr mises /?rIrl % SG^^/01"
Z (plekse print)
• Si nature el Title (Wkall-
(over)
DOH-1555 (02/2004)