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Pellizzi, Pasquale
.. 4t cfl NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name Firs Middle Lajj��t Sex a$ p.24,,L� A GXw.,1e2 !i, z Z / r‘1L e-.. Date of Deat Age If Veteran of U. . Armed Forces, %At'6/2.o)l SI War or Dates Wo!'I& t ' lam. }- P --- of Death Hospital, Institution or i� ) Mown or Village f�;-o 5 t-,k,'i- Street Address «N h / :44 L ft V anner of Death®Natural C e Aco�dent Homicide Suicide etermi ed Pending la .0 Circumstances Investigation iLi Medical Certifier Nam Title 0 7091,1. L---t.,-td,,, c-v-J-y ivt Address A I P. i n d� Certificate Filed District Numve.4,2- ....cr ---ix- Register Number own or Village S- r-v-i'o _ r,i, S 1 5-0 J ;; ❑Burial Date —Cemetery or Crema ❑Entombment ` /)-7-/ )'/ ikeV;C.w �'-'e. Y-- Address (/ ®Cremation 0 �r 0,-- /, 4 r' Date J 1 Place Removed Removal and/or Held H and/or Address tO Hold 0 Date Point of N❑Transportation Shipment 0 by Common Destination Carrier El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Ho s 4., Dt-L erµ t' I-�a.-, -1,- . ©o`-te/f Address \i• ,' Name of Funeral Firm aking Disposition or to Whom I Remains are Shipped, If Other than Above Address fr I Permission is hereby granted to dispose of the human rem ' crid aboveas indicat Date Issued I�a21/7 Registrar of Vital Statistics trb•� ` . -, -' C� (signature) District Number 4+5 o ( Place cs�" 'r eA ,A) /• I certify that the remains of the decedent identified above were di os of in i•ccordance with this permit on: ILI Date of Disposition 'tI Z3)'/y Place of Disposition i IL `r e(4„, 2 (address) U U l (section) (lot numbed) (grave number) (c► c Name of Sexton or Person in Charge of Premises rit J ` tep _ «nft 2.. �f('please print) to apc row Signature AIL, Title (over) DOH-1555 (02/2004)