Serro, Anthony es 14
NEW YORK STATE DEPARTMENT OF HEALTH # is
Vital Records Section Burial - Transit Permit
Name First Middle` Last Sex
A t\on rr d ,�"!, L 2
Date of Death . C Age If Veteran of U.S. Armed Forces,
3/ /a oil l� 7 War or Dates
2 P - e of Death Hospital, Institution or �; f /
5 Town or Village 6�r _� _ Street Addretss -�-�r c�c2_ /70
ner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑P ding
tii Circumstances Investigation
LI
tu Medical Certifier Name Title
Address
Ids / k c ‘L, cr-, � / N ,rt /etai
Certificate Filed District NumberRegiste Number
own or Village �L �n t�Se"-- 5-J a j
❑Burial Date t� Cem ery or Cremator!
❑Entombment ` /a E. / r h ✓C L� C to A.a�t
Address v
y]Cremation LY ,\Ge.n 5� N e� jot/
Date U Place Removed
g ❑Removal and/or Held
and/or Address
M=` Hold
C
0 Date Point of
Transportation Shipment
15 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to ..��-- Registration Number
Name of Funeral Hom �� .Ma>� l��ltfct '+a lc Q 0 it"t"$
Address7 activ.,-., Ave !It• p, C(AidsZ
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
fa
Permission is hereby ranted to dispose of the humaremains describe4above as incl. ate .
Date Issued i/7/a ' Registrar of Vital Statistics a'- p�� " C' ' .
(signature)ig
11 District Number 5 —') / Place z�
(!6
/
I certify that the remains of the decedent identified above w re disposed of in accordan with this permit on:
k �
Lu Date of Disposition I/S1 i'! Place of Disposition ht�t///✓ e /�--
12 (address)
CC (section) i (lot number)( (grave number)
CI t
Name of Sexton or Person in Ch ge of Premises 'a Si,v4-
2 (please print)
Signature 1 e rgiewrtee,.
(over)
DOH-1555 (02/2004)