Guariglia, Vera NEW YORK STATE DEPARTMENT OF HEALTH - # 377
Vital Records Section rr Burial - Transit Permit
Name First x 1 Middle Last rN Sex 1
boa le- iq i la
Date of Death Age If Veteran of U.S. Armed Forces, U
CS I 17 J 2 U q 3 War or bates
• Place . Reath Hospital, Institution or
City Town • Village QV sbur'/ Street Address �
en es-rn o oil 4- cQ C. 1 4y
Manner OT eath �� Natural Cause Accident Homicide Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Roslyn '5 &6-C 1-'0
Address
yZ G.ue(-le Loo.r.L CxyeAnSlner , N I 1z.go�-f
Death 'ficate Filed istrict Number J Reister Number
Cityeown4 Village Q n,g%0j )
0 Burial Date Cemetery or Crematory
Entombment 0`�i i 9 I ZO l l.9 Pine v i r Lk) (,r e()ia+O ry
Address
iiiiliii:toCremation l/�
UOIVDY V.-no-A Q0 een� . oo / 01 izeoif
<>» Date dace Removed Y
g❑Removal and/or Held
and/or Address
t Hold
#t)
0 Date Point of
8.5❑Transportation Shipment
5 by Common Destination
Carrier
-:_ Date Cemetery Address
`:- n Disinterment
Reintermentft
Date Cemetery Address
7 Permit Issued to Registration Number
{�
Name of Funeral Home C..\-- r ct \ Ho - C i o
Address
i!!') Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
l
Lit
L' Permission is hereby granted to dispose of the human remains describedib above� d
\ as indurated
Date Issued --)1 "1( I4legistrar of Vital Statistics �C �-%t ��!-� t.,_
(signature)
District Number cbciThPlace ( O us--r- Q T rj L.Ls2.52- 1—)
I certify that the remains of the decedent identified above were disposed of in accord ce with his permit on:
� 2
l� Date of Disposition 612,014, Place of Disposition �E'4' g.J t
2 (address)
iti
U
Et (section) if (lot numbSovow (grave number)
zName of Sexton or Person in Charg of Premises *q
( ease print)
Signature a Title
nitro -
(over)
DOH-1555 (02/2004)