Constanzo, Dorianne f L11 b
NEW YORK STATE DEPARTMENT OF HEAL Burial - Transit Permit
Vaal Records Section
Middle Last S
_: Name First / Aarh%�. ed Si 6 mac) t 0
Age It Veteran of U.S.Armed Forces,
f Date of Death , c2c5 / War or Dates _,
Hospital, Institution�Pr ,�
City,k�e of Death Street Address Ofro<(JS 1i-CLS 43,P,709
Town or Village ��: � 1y � Pending
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Manner of Death Nlatural Cause ®Accident p Homicide ❑suicide [�UndetermCircumstances 0 Investigation
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Medical Certifier Name i Title 1
.11511-li 0 Ca.A.IN/A/e-14/4,1
Address_3 e - -1- /L C 'rt. Cs itil , re3/
= Death Certificate Fled District N I66 ' I Register Number
City,Town or Village l-h I AJs i-i— _i S 1 L
DBunai Date ?/ /21)1�. C �nY'/,ti7 J Crematoryor c,1t i rl/9- 7'Ril-t i'`�
'' Entombment r� ,�a- t
❑Cremation Address8/ a.c. f,@ 7C"oe ,-• 48 c "/ � �J 6 l
Date Place Removed
p
Removal _ and/or Held
andior Address
M Hold
Date Point of
0p Transportation Shipment
4,;,:„ by Common Destination
Carrier
• p pisirrtermerit Date Cemetery Address
` Date Cemetery Address
'< p Reinterment6, Permit Issued to _
Name of Funeral Home j4.0,1 i �f-- / iAJ I Registration Number
Address, - 61,1 iv' 5 2 C •C 3 s /1 i` h d O /
:` / (' Disposition or to Whom
�`: Name of Funeral Firm Making
Remains are Shipped, If Other than Above
a Address
111-1
'' Permission is hereby granted to dispose of the human remains 'bed above as indicated.
"<.: Date Issued 0.4, / 2 s J i z_.Registrar of Vital Statistics w G&A4-1-Q — -
District Number 5 Go 1 Place 6 1s2„,,s 1 t a" '1/41j (2 1O 1 �m
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MI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition •
(address)
:y sk (section) (lot number) (gtave number)
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tg Name of Sexton or Person in Charge of Premisestii &base a+ H
Signature Title
(over)
DOH-1555(02/2004)