Celeste, Pamfilio v 9rjz
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:< Name First /)f� Middle Lastn ( S x
/'19-MF1G/O t_6'Lc`ST6- I /161Zbr
Date of Dea Age I If Veteran of U.S.Armed Forces,
k-> I Z/28-//(v 9 6 I War or Dates (,J 1") . .
Place o Death ' Hospitalnstitutior)r 1
City, ow •r Village Q U� �S g U Street Address �y/L - t!i M1-42 ec,,) (yes-Adr6-,,L
faMann- of Death Natural Cause 0 Acci ent Homicide 0 Suicide Undetermined Pending
ei
Circumstances Investigation
lu Medical Certifier Name (' Title
in /KoSL" , ) JoCoL f /. (�,
Address.....
,:.::,,--.,- t,j 191/44...6-,..) r_erAfT--6,,,-1._ a a...4..) 6. (.,--4-) 0 U61.Y'Aik 67
Dea cafe Filed ,.Th, ric N�uumber 8 Pleigster Number
Ci , Town Village (j Ubtf.")1
❑Burial I Date f Cemetery a Crema o
❑Entombment iz/ 2"9/�� �(..Jer U16,3
Address ,nn
/( Cremation UfYlG6� ►Lp , Qu6.z.:—Aks a v t—
Date j Place Removed / /Removal I and/or Held
2 C and/or Address
Hold
0 Date Point of
E Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
C Reinterment Date I Cemetery Address
Permit Issued to Registration Number
L Name of Funeral Home . \C--c' ��,i•L,� N Hum C C�t 1 ?L
Address
Name of Funeral Firm Making Disposition or to Whom
li Remains are Shipped, If Other than Above
Address
l=
fa
Permission is hereby ranted to dispose of the human remains described a ve as indicated.
Date Issued` 0,Q( (asgistrar of Vital Statistics -K ,.__ "n'',...,,
(signature)
District Numbec,S rm Place V 1 c
I certify that the remains of the decedent identified above were disposed of in accordan - 'his permit on:
Z
its Date of Disposition /Z/ /1it Place of Disposition Pine_ 1/ ..� e./- ,v1e 74,'y
I (address)
tit
re (section) 1 /` (lot number) (grave number)
LzName of Sexton or so in Charge of Premises .J v..l%a.yt (�4--eviaC, e-
(please print)
Signature ak'y Title e', -/' �y U�� �
/
(over)
DOH-1555 (02/2004)