D'Andrea, Nicholas 3l
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Bu ial - ransit Permit
iii Name First Middle Last D, �c1`�e0` Sex
N
cv,a ks i�
Date of Death Age If Veteran of U.S. Armed Forces,
QLJ I 23 l zo i Lo 2.7-- War or Dates N 1 A
Place of Death Town Hospital, Institution or 4 For a-
, ', T Lc,�Y1 e. ee Street Address �a�a 1-�p}�� r*k ��{� G` a
Manner of Deat Natural Cause Accident Homicide Suicide Undetermine�9 Pending
Circumstances 'investigation
iiiMedical Certifier Name Title A
NI • (. 5tICkSub('QYI1etuOium `i\
: AddressAddress
Nlcd rat 1 Cen4e , Al ri ts1`(
<<a Death Certificate Filed �' District Number Register Number
PO 00r LaV-eG-Mrly .
a e Cemetery or Crematory
❑Burial 0 '2-S ) �)lD Pine VievJ e.Y' emafo(y
Addres 7
::: XCremation Uvcx�her (d i , a)rens�u�'y / ,JU� _ Iz$C} 1-1Date 'Place Removed
0❑Removal j and/or Held
-.. and/or Address
Holdto ,•
Q Date Point of
ihl❑Transportation, Shipment
15 by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
: l Permit Issued to _ Registration Number
Name of Funeral Home _ Ri4t6 -`,%0 —� �y4;7" 0039
< :3 Address }
L If &--rrz'" ., 0 0 ,4 es urn /y
/2. t
Name of Funeral Fiem Making Disposition or to Whom r 1
Remains are Shipped, If Other than Above
Address
t
;' Permission is hereby granted to dispose of the human remains escribed abo e as indicated.
ill Date Issued 2,S7/(/, Registrar of Vital Statistics, )f1cz.i'�
(signature)
pill,, District Number Place 1 c__
S10S /
I certify that the remains of the decedent identified above were disp sed of in accordance with
this permit on:
1:.:; � 4—
Date of Disposition I Z1���, Place of Disposition �!lw V c.�-� L
2 (address)
uj .
U)
CC (section) t numbee (grave number)
O Name of Sexton or Person in Charge of Premises �c;f7will
(please print) 1
11 Signature Title ((� 4L
(over)
DOH-1555 (9/98)