Fuentes, Barbara NEW YORK STATE DEPARTMENT OF HEALTH ...10 ""`
Vital Records Section Burial - Tr nsit Permit
Name.- First a Middle Fes , Last I Sex
Date of Death A e If Veteran of U.S. Armed Forces,
Fla .Dl�-/.4O/� V 7/ia. War or Dates /9 ? ,a-d4QCE
Place • Death - Hospital, Institution or
Cit , Tow or Village Fe,er4---Jezija D Street Address
141
0 Ma -- of Deattratural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
ill Medical Certifier Name, Title
eill/ / P G/9-e/ /79 D.
Address
63096a0&J,g/ FoRT eehcz-,ei /v,/ /.'d 'J'
Death -•"ficate Filed District Number Register Number
City own .r Village pa AT. V i9RD 5755 10
❑Burial Date.a..1/, 6/ 0 45"- Cemetery qr Crematory
❑Entombment Address
jatremation 4(/E-2/—C aemt/ ,(/�/ /2PQi
Date / Place Remo' d
❑Removal and/or Hr
': and/Holdor Address
M=`
ta3
0 Date
Transportation .11
Li by Common Destination
Carrier
:::.:❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Homeill 90 / /ay,/A/ 724i. /f7JJ917 - b///7
Address oD, 13 40X44n7 /-"oR7 '-N,/ , /.26V7
gip Name of Funeral Firm Making Dissition or to Whom
Remains are Shipped, If Other than Above
a Address
Lit
Permission is hereby granted to dispose of the huma r ins described bove as indicated.
Date Issued Oa lo i. Registrar of Vital Statistics
(signature)
District Number 5 7
'155 Place jj,-7t_ 1,6 CIC.00ZA-d
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
al Date of Disposition Zi6lic Place of Disposition i(,n41 cior,,-.
Ili
(address)
w
CC (section) (lot number) (grave number)
`,. .
ci Name of Sexton or Person in Char a of Premises tom'
2. (p ase print)
til. Signature ''v . T-- Title COCA i e
(over)
DOH-1555 (02/2004)