Golna, Adriana NEW YORK STATE DEPARTMENT OF HEALTH - ft 3
Vital Records Section i A. Burial - Transit Permit
Name ofFirst Middle6. Z ��—Last S
Date Death � ` Age If Veteran of U.S. Armed Forces,
I /
a a(2— c� War or Dates
:14 of Death Hospital, Institution or �''
Fii City, own or Village 6l�As FeAltS Street Address �Lc t' )�11 s Nor
anner of Death Natural Cause Accident 0 Homicide D Suicide Undetermined Pending
W. Circumstances Investigation
u l Medical Certifier Narfiv Title
g4 r a -,1 • PA,L g , ..
Address U v
CA - I, ��5 ,
-= D .0 5 M) �1 1 N• T I t )z
s-at ertificate Filed / District Number O ` Register Numbe
City, .wn or Village 6-J S iL.
I Burial Date Cemetery or Cremator
1 /I 7 (aa(Z ,-„, 2V.Ci.J 6r•"-'1��
❑Entombment Address
; ®Cremation Q LA � „`T /13, ✓
Date ) Place Removed .
Z Removal and/or Held
❑and/or Address
M Hold
U
0 Date Point of
r. Transportation Shipment
t��
G by Common Destination
gi Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to / Registration Number
gg �h /.�Name of Funeral Home srt. 4Aet�4- I ta" J.c j . 6,-,E7'`78
Address
„Stlerrn ., Ave 6r. l Ai y laxai
Name of Funeral FirmIing Disposition or to Whom 9 '
•
Remains are Shipped, If Other than Above
';, Address
CC
ill
'`` Permission is hereby granted to dispose of the human remains described above as indicated.
lili_. Date Issued 1/ 7/i 2.--Registrar of Vital Statistics V"fX -'k)`/1/4- _te
(signature)
District Number s 6 0 ' Place 6 6,,,,--s Ztk\ ,S Dk/
k
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
til Date of Disposition l A15 /i L Place of Disposition Inc trvJ r rv►-c of pa'-
(address)
Ili
VI
CC (section) 7 (lot numb) (grave number)
ci Name of Sexton or Perso in Charge of remises /1sqt r ' if/IAA
ILI ( A_jj
Signature (please print)
411 Title C rh '
J
(over)
DOH-1555 (02/2004)