Pascucci, Joanne Feb 18 11 04:17p TLC 5168870043 p.1
NEW YORK STATE DEPARTMENT OF HEALTH r �:�'
Vital Records Section Burial - Transit Permit
. ; Name First Middle Last S
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Date of Death Age If Veteran of U.S.Armed Forces,
- / C0 _ , 11 oZ War or Dates
Place of Death Hospital, Institution or J- 1
tZ City,Town or Village yUp. t-(-t s7.- / Street Address kJ 5 0 /'�-pSp c?,#,l G4r Irt Ssc1-
CI Manner of Death Mtural Cause Accident ❑Homicide ❑Suicide Undetermihed Pending .
Circumstances Investigation
La Medical Certifier Name Title
G /de e c i.9 ot�iSr-G cu,-er'�
iii Address
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Death Certificate Filed District Nut ( Register Number
er
rhheV Register Number
City Town or Village j/). / tC.rtr74,,e�f\ S/ �1 >ZS
Date / Cemetery or Crematory
❑Burial
❑ Pre y
Entombment Q s 2a- �// '',,A-10 u r e k712V
Address
[ emation 61Fr bvc . fU‘V.
Date Place Reproved
gEl Removal and/or Held
and/or Address
b Hold
0 Date Point of •
I:L69 Tans nation Shipment
cl by Common Destination
Carrier .
Ii
Disinterment Date, Cemetery Address
❑Reinterment Date Cemetery Address .Permit Issued to Registration Number
Name of Funeral Home/71///f,e cJ/vim Q r� (rijad(4,
Address /
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
a Address
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Permission is hereby gra ted to dispose of the human rem ' ribed abo is indicated.
I:IA Date Issued el..) / �/
/ Registrar of Vital Statistics _1�� �,�rc
District Number> ps/ Place �� w S l tits- ,v1N
}."- I certify that the remains of the decedent identified above were dis ed,of in accordance with this permit on:
AiDate of Disposition h/ZS'1l Place of Disposition . IN,V;(,ii C`/web('iwa
(address)
to d .,
t (section) , (lot number) (grave number)
Q Name of Sexton or P on in Charge of emises r•t ke' M.l4
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f Signature ��� Title }1
(over)
DOH-1555(02/2004)
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