Ditrani, Dolores NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
m. Name First Middle Last x
€> Date of Death Age If Veteran of U.S. Armed Forces,
111�>_ ro 4' — 14 Co 3 War or Dates )i t)
Ii.4 Place of Death Hospital, Institution or
•.:.;•._gbig Village I Ylc.41 coo Street Address
El Manner of Death fi71 Natural Cause u Accident El Homicide EI Suicide EjUndetermined El Pending
Circumstances Investigation
ttE Medical CertifiesName , - / A Title
i r 1e ( & ltt
iiiii ddress
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Death rtificate Filed
... District Number Register Number
City, r Village /ncI 1Ct_v) 1. c_Q
ffiiiriBurial Date pmet7yorCrematory1
>' ,Entombment Address
:1Crema Q
:: I)Q..en5la ✓ / V
Date Place emoved
•Z Removal and/or Held
O and/or
� Address r;
Hold
to
0 Date Point of
ai O Transportation Shipment
. 25 by Common Destination
iiiiiiiii Carrier
Disinterment Date Cemetery Address
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Q Renterment Date Cemetery Address
Vig Permit Issued to Registration Number
t
s Name of Funeral Home I 1/Rr- y I`Jo Mt/ d g g
// l /
>' Address
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:> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
., Address
a:,
a : Permission is h reb granted to dispose of the hu re ains descr' e bove as indicated.
`: Date Issued g 9-1 ) .li Registrar of Vital Statis s
.1 (signature)
''s District Number c9d S Place l., Witt")i L1-k. __
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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.: Date of Disposition tI/LZ f f tf Place of Disposition 4 ),:.1 C ,tcr __
(address)
i •.
a" (section) 1 (lot number)('. (grave number)
Name of Sexton or Perso in Charge f Premises Ar, ,-3 total
please print)
Signature / Title acionf
(over)
•
DOH-1555 (02/2004)