Labombard, Joanne NEW YORK STATE DEPARTMENT OF HEALTH 190
Vital Records Section Burial - Transit Permit
giiiR Name First Middle Last `_ Sex _
�Oar�n e. ('rlcy-; e La borrlb r-c) F-
`, ' Date of Death Age r - If Veteran of U.S. Armed Forces,
l 1 i i- 19 l�� War or Dates
Place of Death Hospital, Institution or
it City, Town or Village P r--. 1-2 Street Address GO 5h\ � -, ,
Manner of DeathLAi Natural Cause J Accident �Homicide Suicide ErVCDCN
determined 0 Pending
Circumstances Investigation
It Medical Certifier Name Title
0. 3e nn, R \ \ale l`i\0
Address 54 3 3+ 4 t10u C YO H r-yIL I Z gO9
Death Certificate Filed District Number ..1 Register Number
Eli City, Town or Village r�` e \ )J'� 5 7S0 3S
:1: ❑Burial Date Cemeter Crematory
❑Entombment I I�' ) r oYi ne.),
Address iiiiiii:i piCremation 2 ( Quo, 1 nn `` Q ., n eesb, ! 1 Z c�
$O I
Date ' Place Removed
7 Removal and/or Held
....:'—'!
and/or Address
Hold
0 Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
<< Q Disinterment Date Cemetery Address
. Q Reinterment Date Cemetery Address
iiiiiOil Permit Issued to }rn Registration Number
Ili Name of Funeral Home 1 1(� c)neT RA .^ 9 \--\orn e (D10 4--
: Address1.1 12
<> Name of Funeral Firm Making Disposition or to`Whom
Remains are Shipped, If Other than Above
Address •
al
":` Permission is hereby granted to dispose of the human remains described above as indicated.
pil Date Issued `IS )iy Registrar of Vital Statistics QQq, nip. vi,,/
(signature)
District Number 5.5,0 Place CtA Ltd
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ,-/9-( Place of Disposition /1Aa.(�//�,,./ /7,441/
(address)
aui
(section) (lot nymber) (grave number)
J r
ii Name of Sexton o , er on in a of Premises p Ay / 1 _
?z (please riot)
Signature i^ .4nci Titler___;)6/717/fhl<- 4-7-
(over)
DOH-1555 (02/2004) •