DelValle, Jose -I 0 S(o
NEW YORK STATE DEPARTMENT OF HEALTy
Vital Records Section Burial - Transit Permit
Name Firs, Middles Last Sex
pSG_ J LA,6•t C,L V/cA, tlam— /i'lAt
Date of Death Age If Veteran of U.S. Armed Forces,
Ov�• �G,ao (Z 63 War or Dates 1'67-- 73
• Plac= : Death `� Hospital. Institution o
W Cit, , Town,•r Village G�. ti.JVt-- Street Address `\ S i-_/5 �� `-�. ('-' ;V�--
Man _' - Death Natural Cause 0 Accident 0 Homicide 0 Suicide E determined Pending
ircumstances Investigation
W Medical Certifier Ntlame Title
CI 4A,LL E1A�:a ,I.J .
Address � � ,� � ag�b
3 P L� �jt-C-69 1 ,`rt 1
Death icate Filed ( 1 District Mumb Register.Number
CI , Tow,or Village r, �- 3 If
- - Date A J, Cemetery or Cremator
._Burial ►V 6U. i , Nfll.)--- ;ACV, c�,✓ C �...45r
Address
EY Cremation ��e.--44S,4,,,,r, ti6.--> r•Pre-
Date 1 Place Removed
Z —Removal and/or Held
—and/or Address
- Hold
O Date Point of
55 Q Transportation Shipment
E by Common Destination
Carrier
Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
Permit Issued toRegistration Number
Name of Funeral Home
G✓is 44)st- fi,,eri.l I-4'Arc _-.c_ 40 `�`/-�Address `� c?
1 of nn cv� jm e / C(' /0. I. C O�
Name of Funeral Firm Making Disp sition or to h
Remains are Shipped, If Other than Above
Address
tl
Permission is hereby granted to dispose of the human r• • • ,scribed ov s ' icated.
Date Issued Ja f•Z` //.2— Registrar of Vital Statistics Up • iti/4
y j K ,mot—• a •re)
o r"District Number -3 PlaceF� i1Je_1..) / ®r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- � {,
WDate of Disposition al I el Place of Disposition I ihtV it litiaf►id+----
2 (address)
W
CC (section) , (lot number) (grave number)
Q Name of Sexton or Person in Chase of Premises t,al' ,SirW�
(please print)
W Signature ! - Title Mainr tits
DOH-1555 (10/89) p. 1 of 2 VS-61