Leombruno, Elaine NEW YORK STATE DEPARTMENT OF HEALTH Itc
Vital Records Section ' N. Burial - Transit Permit
i Name First Middle Last Sex
DaI�n-c. f �-�Vn 1-e-ombruno c- -i
Date of Death Age ' If Veteran of U.S. Armed Forces,
5V CLj\ �-5 l 201`}- , _car or Dates d
of Death Hospital. titution or
,' C. Town or Vii G k e PQ i l S , ddress G erg r \\s P;fa I
anner of Death Natural Cause f Accident ❑Homicide 0 Suicide ❑Undetermined Pending
Circumstances Investigation
r Medical Certifier Name -- Title
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Address _
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Certificate Filed ! District Number Register Number
, own or Village `e`lS Pc \\S Q J 2. 5 3
Date Cemetery Cr
❑Burial 05 I ag i 01 L4 p-i n-e_ v,P_1LK t-a✓'
Addres/s�,
Cremation `h _f ._Scila , , ®Uefns b cr y / NI i ?-go`# --
Date I Place Removed
g❑Removal and/or Held
and/or
Address
Vg Hold
Date T Point of
0 Q Transportation ' Shipment
el by Common Destination
Carrier
0 Disinterment Date i Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
Y- Name of Funeral Home Ha/ rci I). keC Ft -/ tome Of I 3C)
Address `l LQFQ-y c 3f. , Ou_k_PJ)SbLA-a j , /UP.W Llv,k- 1 'Oy
. Name of Funeral Firm Making Disposition or to Whom
-. Remains are Shipped, If Other than Above -
' -- Address
S Permission is hereby granted to dispose of the human remains described above as indicated.
.:.r Date Issued 5 1��II y 'Y Registrar of Vital Statistics U CA-1
�.�� (signature)
}, District Number 5601 Place CCZA_ 1 �j N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition 5/3o I M Place of Disposition 49riAud 6"1t.--
(address)
Sly
fE (section) Jf (lot number)r- (grave number)
Name of Sexton or Person Charge of Premises + 8is+t
ki-
Z (please print)
4 i Signature �` ,/L, Title C'E j
J
(over)
DOH-1555 (9/98)