Corentto, Sandra NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First n 1 Middle Last Cn�e( -} Sex
--, Date of Death iZ Age If Veteran of U.S. Armed Forces
CA 1�)5 7 _ War or Dates jNll
Place of Death Hospita stitution or
J? //��
t Town or Village l�1€nS FA 1.1.s'" . , Street Address 6)CrIS Pt il j —11b.C_Pt )-
Manner of Death Natural Cause Ej Accident ❑Homicide 0 Suicide D Undetermined Pending IL Circumstances Investigation
Medical Certifier Name Title
Oav A Cunn i njeven t--1
i Address
:,:is?
3 1 r^bn 4e C A-e�' G-lans Fot It S, 1U y i Z8'U)
x< th Certificate Filed District Nu r Register N mb r
City Town or Village Ck G L ,.J S re ,S i )�d/
Date I Cemetery or Crematory
*` ❑Burial DCI 1 /y 1 o is Ti Y i° V I I ) Ccemco-ory
Addr s
Cremation ka\l-e - V.(2 Cuk_orslour4 1v 1 1281)4
Date ; Place Removed /
Removal and/or Held LJ
and/or —
i,:: Address
Hold
Date ,wint of
NQ Transportation j Shipment
E by Common Destination
Carrier
::`: �j Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
r 3 Name of Funeral Home Bake' F erc-1 //ome Of l 0 ,
3 Address
lI Lrr czyetfe • , ut-uf-nsoi-kad , Ne u Vor/ l&?�Gy
. .3 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
#
f�
<>: Permission is her by granted to dispose of the human re ains d cribed bove a- indi • ed.
II.1 Date Issued °LS' Registrar of Vital Statistics /! c. ,. ti9A—e
(sign ure) (
IT District Number 5 c/ Place
-14
I certify that the remains of the decedent identified above were disposed of in accordance wi this permit on:
EDate of Disposition cl infliT Place of Disposition ge4:U, Cr' 0!li..-
2 (address)
UJ
to
CC (section) Y n tuber (grave number)
0 Name of Sexton or Person in Charge of Premises �tc jeos,virl
it A (please print) 0
94 Signature Title jri ttif tOiq
(over)
DOH-1555 (9/98)