Domenico, Carrie f 7
NEW YORK STATE DEPARTMENT OF HEALTH # q
Vital Records Section .Burial - Transit ermit
Name First 4d1le Tist Sex
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Date of Death Age If Veteran of U.S. Armed Force ',
2 / 7 / o 3 g War or Dates s.1/,f¢
of Death Hospital, Institution or:'WA own or Village I L(3,js reztd,s reet Ad ress (y 3f C 'ü - c •C--,
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itanner of Death❑ mi Natural Cause ❑Accident Flocide Suicide ❑Undetermined m Pending
laCircumstances tvestigation
tu Medical Certifier Name A (� TitleM CZ Si Kc ,A) , e-,.) / [�
Address ,f/g2.,
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Death Certificate Filed District Number Register Number
• City, own or Village Qgit j _s-10O / y�--
Burial Date Cemetery or rema ry
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['Entombment Address /�`� IL.-y _ �?'
emation ul U .. v� C v ,u s.d t .7
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Date Place Removed / i
Z❑Removal and/or Held
9. and/or Address
CA
Hold
0 Date Point of
tL Transportation Shipment
t
ci by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
>> Name of Funeral Home 2 01 I3 6
Address
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ell ---/-7-6...,-1-- S—;2- C7 06-e7.--t)—r
i> Name of Funeral Firm Making Disition or to Whom 7
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Remains are Shipped, If Other than Above
Address
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L Permission is herebygranted to dispose of the human remainsi" described above as indicated.
Date Issued . 7 I I I / 17) Registrar of Vital Statistics WkW
(signature)
gii District Number 5 b 0( Place 6(its ��` ` s co o
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
111 Date of Disposition 71 I I-I((, Place of Disposition �oc t�Vv ( w,..,,
W (address)
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CC (section) if
(lot number) (grave number)
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• Name of Sexton or Person in Charge Premises nSt17 r enncfi
(please print)
La Signature �� Title r(lfP4jO.
(over)
DOH-1555 (02/2004)