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Petrucco, Herta
# V10 NEW YORK STATE DEPARTMENT OF HEALTH ,- , Burial Records Section - Transit Permit Name First Middle, Last Sex �t'r Ite, Ne��i k'zkcQcco F Date of Death Age If Veteran of U.S.Armed Forces, ggiti t 0 /OS / ao"-1 �1" War or Dates N /A Place of Death �^ Hospital, Institution or - City,Town or Village V\e \S V•`\S Street Address la Manner of Death 0 Natural Cause Accident 0 Homicide 0 Suicide nUndetermined ri Pending Circumstances Investigation LI ui Medical Certifier Name Title `-fie 1'kss 'Decr� C'`1 . , Address Death Certificate Filed I District Number Register Number iimi City,Town or Village V5( (, 1 �� :;El Burial Date Cemetery or Crematory 1OIbC �a0\ P'%� \i'‘e..� t�r-t.w.e�oi"-I ['Entombment Address ®Cremation Qvc,\(\e . R©GQ Q,uL2�sb0"I '-\ 1 a$ ©y _ a Date Place Removed Removal and/or Held for Address te Hold Date Point of fkQ Transportation Shipment a by Common Destination Carrier 0 Disinterment Date Cemetery Address 'Q Reinterment Date — Cemetery Address i Permit Issued to t— �(7 Registration Number :: Name of Funeral Home Maynard 'D.�0.ker Funerct I 1-4 Q 1 10 • >` Address 11 La-c.ye-+4 e Sir ee t Queen sbu f < Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above EAddress Permission is hereby grant to dispose of the human �: ains de-.. 'bed a. •ve as indi�:ted. Date Issued /v 6, o�n f Registrar of Vital Statistics i - . ,- A. iaiir '' (sign-, re) District Number Place-;;:ii --AP.efr Ea-,-ted; .i I cI certify that the remains of the decedent identified above wer- disposed of in - :,dance ' this permit on: E. ;i Date of Disposition/Olv�r Place of Disposition .��j(J�1 jA , ' sue 3 (address) f CC (section) - _nuu ber) i (grave number) aName of Sexton •iin %h e of Premises '" ' a C� // Cti (,please Pfin9/1Signature .- Ttle eAd< /J. 9 . (over) DOH-1555 (02/2004)