Catalano, John NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name Fi n11 ��IMiddle C Las,+t Sex
Date of Deat Age If Veteran of U.S. Armed Forces,
,/nGt✓Cl ,3 0, )Q/�/ 7� War or Dates 176) /7 cC
I— ce of Death Hospital, Institution or
Cit , Town or Village a I-Ce II-C- Street Address �� s t /% //i9.s 1/c/
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Ci Manner of Death 'Natural Cause 0 Accident E Homicide 0 Suicide 0 Undetermined Pending
tli Circumstances Investigation
ILI Medical Certifier ,_ Name _ Title
-e nil 1` --e r S-id-CP o7i( •
Addpss
ii:il / 426 401 Vil. C-Q(i-eems Z t)f/ ,4/-e k(JK)/A- pe7±/
t1� Certificate Filed ADi tact Number Register umb r •
: it , Town or Village T76 I/ 1/ Ot V 7 � I 5 6 01 7 .
❑Burial Date r
GeeP etay or CJrematory t•�( ' / / A.e)/L -f//J-e Vet(1(c p
C /O 1/4/i;'�/❑Entombment Ad ,
Cremation �C (/o k
' e r /U a ;j'L/,/l` ., (- / 6' l/
Date Place Removed /
Removal and/or Held
a:,❑and/or
Address�
Hold
0. 1 Date Point of
o Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address •
Reinterment Date Cemetery Address
Permit Issued to �q Registration Number
Name of Funeral Home4JCt6' Tcr - /U� CD-Q( 0If fini1Q/4f h C. /,2,3Joi
:: Address n k f
q rine� \�/ ( ` er742 v'i .may /)- / 7
Al Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
Address
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CL
Permission is h r by granted to dispose of the human remains described above as indicated.
Date Issued / /v Registrar of Vital Statistics (A)c--+;,ti
(signature)
District Number r] &Q/ Place G f F"Cn ` I5 N r
<,.< I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i �
lit Date of Disposition t1 7/1/'► r Place of Disposition 1;uL f✓ Orr.-,
(address)
111
Ul
= (section) y of number) (grave number)
Ct CI Name of Sexton or Person in Charge of Premises +� `0, A- Ste,, "
z
(ple se print)
Signature Title iii, etm
(over)
DOH-1555 (02/2004)