Ortale, Isabelle NEW YORK STATE DEPARTMENT OF HEALTH 120
Vital Records Section Burial - Trans t Permit
Name First Middle t � Sex
F—
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1s
Da a De h A e y If Veteran of U.S rmed Forces,
�� / War or Dates
a eath �'�/' . ' Hospital, Institut o 1
Z Ci , Tow or Villa e ,4— C c- Street Address J iJ r IAL75I Arit._
a Manner of Death atural Cause Accident Homicide Suicide Undetermined ding
Circumstances Investigation
tu Mpy1C, e . i r ,INamy Title 4
a
D Address
� E GZ.�`�l/ T /�T�/<�r
Death -=.ificate Filed District Number_ Register Number
City own ,,r Village - c / /ff
❑B ad---
urial Date C- '-tery or r matory / 1,74
['Entombment9 r1"�%// i f/� �...t) l
Ad / j ,
►�"remation ! ut_1L..t,,`_ 71 Y //
Date Place Remov d
Z❑Removal and/or Held
and/or Address
h* Hold
IA
0 Date Point of
E Transportation Shipment
d by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Regis r ion NumZr
e a �7' /
Name of Funeral Hom �j (+ Vf L
Addre
c-i ,4,,,t 9- _ 41_s.-24 -x41,, 7*)i;1_027_7
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
III
Permission is reby ranted to dispose of the human ins described e as i mated.
Date Issue �'J' -�)// Registrar of Vital Statist _iii ",1p
(si nature)
::::::
pi, District Number,�7 5 Place atm.
I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on:
/1
IL Date of Disposition 3-cl- (I Place of Disposition "9 ,wt Uzz;,, (--rvwci or iv,
(address)
ttiu
i*
CC (section) (lot number) (grave number)
0 n
ci Name of Sexton or Person in Char of Premises a ►W ^
z
(please print)
1:U;t Signature Title a fiiilet-r7IR
(over)
DOH-1555 (02/2004)