Scavone, Sharon t cA N
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle < Last Sex
6haebn eztvLne- re male_
Date of Death Age If Veteran of U.S. Armed Forces,
0' c1 1/4 9 I War or Dates
.14 Place of Death Hospital, Institution or
Z City, Town or Village Street Address 50.40A4D8A Sej-1- l
W Manner of DeathUndete ined Pending Natural Cause �Accident �Homicide �Suicide �
iti Circumstances Investigation
tu Medical Certifier Name oi t� DL4-Mateit Tit
Address
/ C twit-h ✓ l- • c`{G 94 K`e •
Death Certificate Filed DistrictDistrictjumber Register Number
City, Town or Village / 5 I
0 0 Burial Date Cemetery or Crema ory
Entombment Pi it e. i(?. AJ t7.,nr►A-g- i i,c'n
Address
iiiiii(2Cremation n ldern-S bi,L(u,` N A.a✓ tivV.,:K
Date Place Removed
2 Removal and/or Held
2❑and/or Address
I= Hold
to
0 Date Point of
Transportationto, Shipment
• by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
iiiiRPermit Issued to _ Registration Number
] Name of Funeral Home C 'f1`l �D , 1 to .�n-�t c l t ,,r i -Aic_., 0636,41
imi Address
11 Lib Libe niet.pie ,fie, 5aigJ i, ;5, A / g'4(
s Name of Funeral Firm Making Disposition onto Whom
Remains are Shipped, If Other than Above
• Address
tit
Permission is hereby granted to dispose of the human rema cried above-as indicat
Date Issued. ja /31/1 Registrar of Vital Statistics '""-,
(signature)
District Number (110 I Place 5 0i/ Ob'r WM.75 I . tz- 16G,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
141 Date of Disposition (®ibIiM Place of Disposition 411,A✓ C e-wtoi —
(address)
Ili
re (section) dot number) r (grave number)
0.
U//hj
ilk Name of Sexton or Person in Charge of Premises ii oiNtt
+r (plea print)
77 Signatureirt
A Title (Wl1 FT4C
(over)
DOH-1555 (02/2004)