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Capone, Daniel if 3 G(f NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First //�'� ! /Middle / Last Sex /..) /�/ 4Ck-L 't s (;4/04 M Date of Death Age If Veteran of U.S. Armed Forces, © /4kX/2a'Y 7V War or Dates /y 6r-796 " I...+ Place of Death Hospital, Institution or � ��/ City, Town or Village Cavf, A Street AddressILI (- ll�s �v�� / W Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending Circumstances Investigation w Medical Certifier Name T�tI G r//q/p4d -I /v3) Address • /0 Pig S / jerk. /L Death Certificate Filed / 7 `// District Number ` Register N mber City, Town or Village / , t 645 SC •C)/ 7 ❑B •urial• Date 0‘/0 9/.-•b/"/ Cemetery or Cwi ato ; ❑Entombment Address Cremation (f-)JeG, „ , Date Place Removed I ' ❑Removal and/or Held and/or F= Address CA Hold 0 Date Point of ai❑Transportation Shipment 0 by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home C A.Qffo k i 1� , 1-E ,_ Co 36 54 Address 470 "oh- 0§1aEI 5;% 4A 4ar,--, S w /Z.k“ Name of Funeral Firm Making Disposition or to Whom liOi Remains are Shipped, If Other than Above 2 Address 1Z ttf P` Permission is hereby granted to dispose of the human remains de cribe ab ve icated. ff 1 iii Date Issued QGA09/10/,' Registrar of Vital Statistics (signature) District Number j / Place ‘1.74.--0 A /0y "` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition (0-(0-(4 Place of Disposition ir2ty.r',. 6.-401.14...., 2 (address) Ui CA CC (section) (lot num ) (grave number) Name of Sexton or Person in Charge of Premises . iirtn Z /A4 /ease print) III Signature Z_ I.--•-• Title C(1 (over) DOH-1555 (02/2004)