Vasta, Loretta NEW YORK STATE DEPART OF HEALTH -rt
Vital Records Section Burial - Transit Permit 5 -
t
Name Firs, e f?- :1-1-ft 111 -_a •
i le �1,ks Sex r
; : Date of Death Age If Veteran of U.S. Armed Forces,
QO�?-0S-- I /I( War or Dates
Place • Death Hospital, Institution or v- -
City, own ,r Village I-1�gutz-(0 Street Address ►P, `I �Z I- No-Lc_
Mann- of Death— atural Cause ❑Accident ❑Homicide ❑Suicide C Undetermined Pending
- Circumstances Investigation
la Medical Certifier N J Title
-J As ��1404.4.
1'�i NINS'ayJ In b
Addffe -) 141 POWs- l NDt fl( l--tL& A)Y
Death Certificate Filed VRtO District Number Register Nu er
City, own ,r Village O Pi l� pt
❑Burial Date Og-07 - i< e 'ete�Qr�`e,matoni-tilmfergz-V
jornbment Address mation ZI Qupt- - 'R Qvp-ps.1.5-2,,tz_v M V riclott
Date Place Removed
Removal and/or Held
and/or Address
t Hold
CA
Date Point of c
I E Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Re istratio Number
><: Name of Funeral Home KILivit41- ` fGThSt 1- '�� 0I01e
mi: Address 136 Ol Ii I /S SS & f /" r 1 Z2O 3
>> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
W
`" Permission is hereby grant to dispose of the human re described ab ve as indica
Date Issued 1- 9 - t 5 Registrar of Vital Statistics 2DQ ,
(signature)
District Number 5�9 Place) L�� 4 Sh(1' k�(i`
iiiiiiiil<.. , I certify that the remains of the decedent identified above were disposed of in accordance with th rmit on:
III Date of Disposition filmic- Place of Disposition ZIL..I e,,,-1-0.r
2 (address)
W.
(section) ll (let num r) (grave number)
` Name of Sexton or Person i Charge of Premises "1il, JuAr
(please print)
iii:ii Signature Title nliv04 ►'f
(over)
. DOH-1555 (02/2004)