Celentano, Charlotte NEW YORK STATE DEPARTMENT OF HEALTH t . '~ c lb
Vital Records Section Burial - Transit Permit
Nam First Middle f� Last Sex_
�no r I D'f`�C'_ LP kti fail O F f✓w le-
Date of Death A�e If Veteran of U.S. Armed Forces,
(6t"'� 0 /8 War or Dates Y1 0
IN Place of Death J/s Hospital, Institution or /D A'l 2-Lq9 1 /4 f7'/
Ci Town or Village /e,j5 / Street Address �� eris a/�
0 Manner of DeathgJNatural Cause ❑Accident ElHomicide ['Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
ili Medical Certifier �� Name , Ok_
� Title
i Mb
ddress
a LUL,'1.Sb(,l
nj
Death Certificate Filed,..., District Number Register Number
City, Town or Villag f�/15 /46 5(,Q 0� d a
❑Burial Date rD c
C ete� r Crem ry J
❑Entombment � ' s' lle l` t ea) ` - y
Addre
,®Cremation 4 ?LLOOASJJL1 NY
Date Place Removed
Z Removal and/or Held
9❑and/or Address i,
11)
Hold
O Date Point of
5 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
:0 0Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home-BpaLttr 1ii'Le i? f/(-4 )flL
CodI f
Address
J± OA tk r d) S-t La-4e. iliZerik k7 22¢.(0
Name of Funeral Firm Making Disposition or to Whom
l- Remains are Shipped, If Other than Above
• Address
#C
LEI
fl` Permission is hereby granted to dispose of the huma emains d cribed ab ye as ated.
Date Issued ,__ Registrar of Vital Statistics �'�(7-e. ,.
�
(signature)
District Number ,5OI Place 6/ems l/s A
I certify that the remains of the decedent identified above we disposed of in accordance with this permit on:
ILI• Date of Disposition W 1 clir Place of Disposition „t()", 6.. .-.)
(address)
W
ta
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises �P \�
z ( ease print)iti '
Signature it -- Title Inigli'vePit
(over)
DOH-1555 (02/2004)