Constanzo, Ronald 1 A NEW YORK STATE DEPARTMENT OF HEALTH 351
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Vital Records Section Burial - Transit Perm
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Name First ;) Middle Last
6OSY772t/dC2-e-D j Sex
-il Date of Death Age - • If Veteran of U.S.Armed Forces,
...
7 o , tri..,t_ I, 4 War or Dates _
1:*;, Place of Death Hospital, Institution or 4
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w.,--, City,Town or Village (1-0( c-iti..N /44-1-c_. Street Address t64,c,44.5 -,;-;14.L._s
Manner of Death[ Natural Cause 0 Accident 0 Homicide 0 Suicide [3 Undetermined 0 Pending
Itrii Circumstances Investigation
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Medical Certifier Name ,..- Title
W ._>irAtAi 8 4 f Air H- 4
it Address /6 O /)/94_k._.s 7- 6-,Cs 9-4-44.5 Afi-/ latie) /
3-4 Death Certificate Filed / en District Number , I Register Number*'• City Town or V .-: ! , (1- N 1 C ...) S-15 e / -.3c g
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.1 Date 'vet or Crematvory ElBurial 7/, i /‘2 ,14.z_ Ce7Y Al -0,1
/ i/i-c c t 157642-ittfri
"1:-::DEntwthment Address
gigremation a I &.t-k.A4-4<G.R.-. 'Pk CALE1.33.6 Lkal A)/ 44(1 il Date Place Removed
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Removal -and/or Held
..,.- and/or Address
Hold
Date Point of
''ttrl El Transportation Shipment
by Common Destination
Carrier •
DDsinterment Date Cemetery Address
o i
Date Cemetery Address
0 Reinterment
Permit Issued to ,--- /.....// , Registration Number
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Name of Funeral Home /904 6 /It- f---- - 4 c____ I9a5
s: Address 1 e ttP,}4.240-4,L1 ..5 7-- 6-1-AC,O-S gcle-C-5 /V/ /die/
Ira Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address — -
7nei Permission is herebyi granted to dispose of the human sins d "bed ve as indi
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1 Date Issued /.4‘,0-- Registrar of Vital S - tics
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District Number 5"&c, / Placethisrt lo t
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a I certify that the remains of the decedent identified above were disposed of in accordance ' permit on:
Fr, Date of Disposition -)lit) it Place of Disposition ProtUw.., Crt,rfor I 6....._
W,4 (address)
!?;44til (section) A (lot number) ,- (grave number)
r...7,1 Name of Sexton or Person in Char of Premises ri,)tyle
El (please print)
i cr Signature
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4)( Title cv4 ,00.,
(over)
DOH-1555(02/2004)