Decelle, Joan NEW YORK STATE DEPARTMENT OF HEALTH', > - .
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HEALTH',
Vital Records Section Burial - Transit Permit
Name `FL% Middle Last Sex
oAt1 "YY1(\RIE _ )E.CELL.E 4 rv\IALE.
Date of Death Age r7 If Veteran of U.S. Armed Forces,
'FF 0 . 1 3 , �c 12- /I War or Dates
1 Place of Death Hospital, Institution or
City,Town Village t�-L,E loS - LL S Street Address ( tv s LI..S t—b s?rTh L.
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
laCircumstances Investigation
iii Medical Certifier Name Title
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Address
39 (a ( N0 5-r La AR(aElvs L .(- -nc 1ag8"S
Death Certificate Filed ` District Nu per ) Register Number
1-1 City,F Wage
age �1.E1,)S 1_L S 5(0.01 6
0 Burial Date Crematory
❑Entombment ` 6 ` ``A O") 14— I Iv v ( EL �E'3 � YY\Pc-TO 2tItvv��
Address
;gCremation . a\ QUAKER R9 QCtF_EtaseuR ) -i\ 1a;2'o4
Date Place Removed
Z ❑Removal and/or Held
and/or Address
F= Hold
to
0 Date Point of
CL Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
im, Reinterment Date Cemetery Address
Permit Issued to Registration Number
nii Name of Funeral Home.- �57 EP-/}t E) ) N�, ()i(o a 4-
Address
10 ,m o i MI t AV\ L a KF C K.c ) IA ( a�--�fs"
Name of Funeral Firm Making Disposition or to whom
Remains are Shipped, If Other than Above
Z Address
i
to
Permission is hereby granted to dispose of the human emains scribed bove as Ind' ated.
Date Issued --/le„Iota_ Registrar of Vital Statistics , .., 7,-,"1 C
(signatu e)
_____d
District Number Place ff c
I certify that the remains of the decedent identified above were disposed of in accorda a with this permit on:
k Piin Date of Disposition it, Il.`1Ga Place of Disposition �\.ckJ CrosAurlo..
is (address)
Lu
CA
cc (section) (lot number) (grave number)
CI Name of Sexton or Per, n in Charge of Premises c
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Signature Title C EEIYa jofl
(over)
DOH-1555 (02/2004)