Pelosi, Patricia NEW YORK STATE DEPARTMENT OF HEALTH , 4 ( t I
Vital Records Section Burial - Transit Permit
Name First Mi dle l_a t Sex --
Poktrz-c...; �. - Peso s e 7--
Date of Death- Age If Veteran of U.S. Armed Forces,
‘) /7/ ao, 1-1 61 War or Dates ,
, Place of Death Hospital, Institution ort� /
own
Z City r Village C r; Street Address ( LoG� 0
0 Manner of Death Q Natural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermi4'Ied D Pending
W Circumstances Investigation
W Medical Certifier Name Title
4 E -L )( Lei - _ ,ni-
Address
07 61- Rv _v:c,, Pit , k`'�ra. , N7 /a) t
9
Death Certificate Filed District Number Register Number
Citw Village r.A->LL. cf.-5-5-1 •
Date Cem ery or Cremat
Burial ll76 /d0 <<t .vie �,e_�- c,4-lam
--- Address
Cremation aGcA� Jr r - li
Date 3 / Place Removed
Z " Removal and/or Held
H and/or Address
Hold
O Date Point of
CL
0 _Transportation Shipment
Eaby Common Destination
Carrier
Disinterment Date Cemetery Address
7 Reinterment Date Cemetery Address
Permit Issued to _ Registration Number {
Name of Funeral Home G?454",),e_ --ra,,e r-.:L 14,-,-�
Address 7_..ge,.......
Av,, L ten`" Air /a 0---,_
Name of Funeral Firm Making Disposition or to Whom
~ Remains are Shipped, If Other than Above
Address
CC
lU
t ,
Permission is hereby/granted to dispose of the human r a ns scribed ov s ' icated.
Date Issued i/ /`( Registrar of Vital Statistics C� i..4/(/
' a re)
District Number ASS 3 Place • l pe:.• /o!/C__
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-
• Date of Disposition 11/b41'1 Place of Disposition gAtti k._ C tole..,
g (address)
UJ
N
CC (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises number),„. (grave
Z (please print)
W Signature Ali.. Title /iZ( t14}{0g
DOH-1555 (10/89) p. 1 of 2 VS-61