Lopreto, John 4f
NEW YORK STATE DEPARTMENT OF HEALTH Cf v)
Vital Records Section , Burial - Transit Permit
Name First Midple Last Sex
4 c hit) Z ,C i A 0 I-1 A 1c
Date of Death Age If Veteran of U.S. Armed Forces,
9 /5_- 0 I ), (a War or Dates L) j,c)_�//
j..6, Place of Death Hospital, Institution or
City, own or Village 13 c L it) Street Address
W Manner of Death El Natural Cause Accident Homicide Suicide 0 Undetermined Pending
Circumstances Investigation
1 Medical Certifi r Name Title
"� T Address /' / f/ 0 1
t/ 1 rV y^ ��,4--. �.: r e.-r�`K,✓ �r /f-r'\J rct,G 1 S / ' ( /,i. o l
Death Certificate Filedc---; District Number Register Number
-City Town or Village J c ( "1), lJ 67 J 0 I I
•
0Burial Date n/ Cemetery or CrematoA
❑Entombment / F- 4 T/N e I,)i fri,) Comte i ti c< l -i'
Address
(Cremation (X vL-c OS ter yAl
Date Place Removed
Removal and/or Held
and/or
Address�
t Hold
Date Point of
85 Transportation Elp Shipment
Cs by Common Destination
Carrier
ID Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to '�i .-� Registration Number
Name of Funeral Home O ' loay ikJtl'i T, Li a 0 / / 3
Address
, -f-/ 5 E Q /.1L. v, i2A,k4,,i IQ Li 7..)- ii
Name of Funeral Fierh Making Disposition or to Whom
10 Remains are Shipped, If Other than Above
Address
Ir
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued q - i'7- ) Registrar of Vital Statistics }.-(1. .1„4.-i-c LCL 'i&,t 6
(signature)
•
ER District Number V_S-u, Place } /
l� `-
>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition q-iq--ii, Place of Disposition 24,V tc,J CriA ori"\.
2 (address)
III
tf:
CC (section) (lot number) (grave number)
ifa Name of Sexton or Person in Charge o Premises gills
w/ l n,JI�'
zj please print)
Signature Title L 24,7/11rrat.
(over)
DOH-1555 (02/2004)