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Sigismondi, Jo-Ann , ....4,.. #7gy NEW YORK STATE DEPARTMENT OF HEALTH • Vital Records Section Burial - Transit Permit Name First Middle Last, Se Jo- 4A. 1 -iid. ,s/ti.ndll Date of Death Age If Veteran (3 .S. Armed Forces, /o/' i/1 r- 70 _ War or Dates —' F. Place of Death Hospital, Institution or Town or Village f,LeAf im,6Uf Street Address ageni ra L1 1.{'nS O , anner of Death©Natural Cause Accident Homicide El Suicide 0 Undetermined f J Pending iLtCircumstances Investigation W Medical Certifier Name Title a & c. e lleme..„ n, . Add6L�r.-7 i f or , Are $�. C9L4-r,-71 i A)/ l So/ D-- • Certificate Filed // T,�^z I District Number // Register Number own or Village c 1e S ��Ir p 0 I c1`f- . Burial Date Cemetery or Cre tory Entombment /0�30 %� l Att ew l ..�tr 4.4,7 . Address (Cremation G v1/4. eASS,,r ,A) • Date Place Removed Z Removal and/or Held O❑and/or Address F_ Hold in O Date Point of Q Transportation Shipment • Q by Common Destination Carrier Disinterment Date • Cemetery Address • Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home, 5,+,,.,re / . J _- - b4. 't oliiiii Address 7 ,..... , Gr, ,v r la ?az Name of Funeral Firm Making Disposition or to Whom ▪ Remains are Shipped, If Other than Above • Address to fl` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued /0/3 0k"---- _i Registrar of Vital Statistics 1"a�n--Q W (signature) District Number 5 GO 1 Place e Lq -svtx\\s , 1\ y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Lu Date of Disposition illilic- Place of Disposition gt iit, r~„ W (ad ress) Cl, CC (section) ,y' (lot numbey (grave number) ▪ Name of Sexton or Person in Charge of Premises 6h .(yw,.o+r Z (p ease print) l Signature 4 /t Title nSulfRik. (over) DOH-1555 (02/2004)