Colontuono, Constance NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle /1 Last Sex
C AS+[AYl C� l .Q I 0/lLt Or10 �l-e+`Y1 a
Date of Death Age If Veteran of U.S. Armed Forces,
j 1_ L -2-0 C Z 11 1 War or Dates ,
Place of Death i Hospital, Institution or r
Ci Town or Village -A rc IL5 . Street Address Gte, n5 f Ii(S -t-ro'pi±ct
anner of Death Natural Cause Accident Homicide Suicide0 Undetermined C Pending
Circumstances Investigation
Fa Medical Certifier Name Title
01
-- - x — RJ 6 is - i(s .� [not
Death Certificate Filed/� District Number Regist Number
Town or Village G(�P,i'15 -
II, 5-00 1 ,o 6
Date meteery or Cre tory _p_
❑Burial 1 - Zc112, Y12 V { T�
I]Cremationi NAddrew (.1_- 1 1'J0 , NI / _ lab
Date Place Removed
O ❑Removal and/or Held
and/or
t, Address
g Hold —_
Date Point of
NQ Transportation Shipment -
5 by Common Destination
Carrier
Disinterment ; Date Cemetery Address
Reinterment 1 Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home � (,( ilex re L ' t'-LJI Yam- /Y)C 0o I
Address (9. efil,L-r-C h La_. e_ Lu ze J� (lt t{co
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
Address
_-
ria
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued I i-`J- 20 CZ- Registrar of Vital Statistics V)CA.- _ ,
(signature)
District Number �iO 1 Place tQ,/t...) -*L
I certify that the remains of the decedent'de ified above were disposed of in accordance with this permit on:
1-
W Date of Disposition II I 7lIZ Place of Disposition Pniu .,) � dt"-
2 (address)
W
(/)
CC (section) /j .- (lot numper) (grave number)
Q Name of Sexton or Person in Charge of Premises L l,r J gti r ff
Z (please print)
W Signature Title CQ4F, N1 ii rdi
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DOH-1555 (10/89) p. 1 of 2 VS-61