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Buchalski, Rosamarie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Per it Ny.Te First Middle Last Sex D ,rnari� By c,ha kKK1 e yr le Date of Death A e If Veteran of U.S. Armed Forces, q -Cc-Z©l to War or DatesNU 8 P e of Death Hospital, Institute t km S i�� ii ;t City, Town or Village ICc- PANS Street Address (.�' Manner of Death®Natural Cause ❑Accident El Homicide ❑Suicide El❑Undeterminde ❑Pending Lt.E Circumstances Investigation ta Medical Certifier Name Title a Mar K Qua CC-Si ma. fri-D _ Address , Sri; Ed t,?curd1 h Certificate Filed p District Number Registe lfber it Town or Village (7 I e n 5 etI Is Soo 1 (-�l c ❑Burial Date Ciatnetery pr Crelm ory ❑Entombment D`"1 - I - ""�O l to ✓✓t 1'x V i e f,V CrtYYIQ +o rj Addres J Cremation (,Lte,ncj , I v', Date J Place Removed Z❑Removal and/or Held G and/or Address F—" Hold to O Date Point of l.!, Li Transportation Shipment a by Common Destination Carrier _ ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home33` r' huryzica ` - }y` I nC_ OCO 11 Address a+ C u-rch a Loy. . Lutt�c ivy I ?gzi-G Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address it Ui Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued R -q- 1 (4, Registrar of Vital Statistics t..Aj C^A Yv"a. k.A),i -W' (signature) District Number 5o ( Place Ct+y DC---- ( !cps kl I (S i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Ili Date of Disposition 1 I1`(f/i Place of Disposition eitt00,4 Ctmr,,- (address) Ui CC (section) if (lot number)(. (grave number) O Name of Sexton or Person in Charge of Premises ritee• St„4k Z (Tease print) Signature a Title (over) DOH-1555 (02/2004)