Barone, Ann NEW YORK STATE DEPARTMENT OF HEALTH n qt
Vital Records Section Illir j Burial - Transit Permit
Name Fir t Middle I Last S x
Date of Death Agen If Veteran of U.S. Armed Forces,
I 1 • �r •ZO (s `1 Z War or Dates N o
1- Place of Death + ' + � Hospital, Institution or
Town or Village Q? ' S t`t1,1�s ,- Street Address GIkr v '(-a I IS 5; rk( I
0 Manner of Death M Natural Cause 0 Accident Ei Homicide 0 Suicide riUndetermined 0 Pending
W Circumstances Investigation
unt Medical Certifier S Name NI
N Title
h(fl P&ozdh
Address r
pe�th Certificate Filed ((�� t District Number Register Number
(City -town or Village ( �,V1 S t'�.�1 (fle i
0 Burial Date CAnetery 1orr Cremato
DEntombment _ ( � .- t n e V l e_tiV rY1G4�
Address
::.:-:[34Cremation Q u-61.15h tA,M ti
(Date ' Place Removed
❑
Removal and/or Held
and/or
t.0* Address
al
Hold
0 Date Point of
Transportation Shipment
C! by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to- Registration Number
Name of Funeral Home 0 re,,` .r l c'c rz,.( 1--9 flit i n c-- O D I(
Address •
e. kULrCk St La Lutzef-A.L. Aly ILS4
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above _
2 Address
tr
tt
a` Permission is hereby granted to dispose of the human remains descri ed above
_ ind' t .
Date Issued 1 a—.2-3D i' Registrar of Vital Statistics / X�� �� "
(signature)
District Number 5 0 I Place C -k1 br C ik y1 S Falls my
"`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tt .• Date of Disposition IL hits- Place of Disposition Si IL, (114)-41-11..,
(address)
la
U,
CC (section) lot number)c (grave number)
Name of Sexton or Person in Charge of Premises ar,-1 S°"'w`�
Zr
A (ple se print)
• Signature �/ Title �}71✓�
(over)
DOH-1555 (02/2004)