Deciccio, Emidio NEW YORK STATE DEPARTMENT OF HEALTH ` ,\ Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sexer
[ ctiIOLD -L< i ►-1 �LCrcczo
Date of Death / / _ Age , If Veteran of U.S. Armed Forces,
f 0 l i /.20 t - War or Dates _
Place of Death Hospital, Institution or
i
City, Town or Village (..,LE N S V-AL`S Street Address t. S �QL�s ��os t' k
L
Manner of DeathNatural Cause Accident Homicide Suicide ❑Undetermined 0 Pending
• Circumstances Investigation
Medical Certifier Name 5 = Title .�
(<DT
+. Address r
r (O0 VARK- S GLENS F,A.c-crs )agb )
,..$ Death Certificate Filed r District Number Register Number
City, Town or Village G Le N S `_A S __5-Ct,O 1 2.-7 CI
Date , /-a (�O ) Cemetery or�rematory
:.c LI Burial (m / Yi o� E i C 0 Ca_ C rn Al o R`1
iiii Address
Cremation ( :-,A,V-E ZoA` Q.-5 c: CNS i ‘.)(L`1 OJT la-To 4
Date I Place Removed
Z❑Removal and/or Held
and/or Address T'
Hold
0 Date -Point of
❑Transportation ! Shipment
a by Common Destination
Carrier
•
U Disinterment Date Cemetery Address
Renterment Date Cemetery Address
p Permit Issued to Registration Number
I Name of Funeral Home, / - _ &titer Fu neccdHorne_
Of i o
Address /i LQr L
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above at indicated.
Date Issued 6/< //5 Registrar of Vital Statistics W� W
4 (signature)
District Number 56 O I Place 6 S RA S r N t)
I certify that the remains of the decedent identified above were disposed offi�in.accordance with this permit on:
t Date of Disposition 4(3II - Place of Disposition -evil...,
Ct-A —
2 (address)
LU
1A
CC (section) il,yt number) (grave number)
pName of Sexton or Person in Charge of Premises c` -?L S 14 -.
2 (please print)
Signature Title fae-sl{fit
(over)
DOH-1555 (9/98)