Pasquarelli, Vanessa NEW YORK STATE DEPARTMENT OF HEALTH
I
' 4 3g 9
Vital Records Section Burial - Transit Permit
Na First Middle Last , Sex
Date of Death ge If Veteran U.S. Armed Forces,
a ca(- f(P a`, War or Dates. NO
- Place of Death Hospital, Institution or
Z City, Town or Village 1A)ar a_i l v.i'ci Street Address Set-17 0 L Rd
o Manner of Death `` Uhdetermined Pending
i �Natural Cause �Acci�nt �Homicide �Suicide �
141 Circumstances Investigation
W Medical Certifier Name Title
CI —ri no*hy M LCr ehy Ooroncf-
52 -HavY late 01pc, G bib i-a 115 N:\I
Death Certificate Filed Distri N !m r / Re ter Number
City,(('owor Village wax t^t',1ib(kr1
['Burial Dateetery or/Cremato
❑Entombment 5 015I) T h e V iC t o ,l�U
Address /2,--\ e l5 bu rt ti
remation
Date Place Removed
gEl❑Removal and/or Held
and/or Address
M=" Hold
Date Point of
❑Transportation Shipment
Cl by Common Destination
Carrier
Disinterment Date Cemetery Address
. IDReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home f r -1 '( - I �t3I (
Address
(9 - 0,1 rch St, 1_ ( K u 7rn Q i _ .e (vy )2$d-fP
Name of Funeral Firmng Disposition or to Whom
Remains are Shipped, If Other than Above
Address
it
I
LI
C.I
` Permission is hereby ranted to dispose of the human remains desc ' ed above as indicated.
Date Issued _ Registrar of Vital Statisti - `vim.
�� (signature)
District Number w Place itija r,,,bgb, `7
I certify that the remains of the decedent identified above.wfe-6isposed of in accordance with this permit on:
C rwwQ4-c"..._
W Date of Disposition -1"1b Z�lb Place of Disposition t•,t U.,,,,
2 (address)
tint
CC (section) dr(Itoct
number) (grave number)
pName of Sexton or Person in Char e of Premises ��""r
(ple se pant)
ta
Signature g Title (REMtilat--
(over)
DOH-1555 (02/2004)