Caiazzo, Joseph NEW YORK STATE DEPARTMENT OF HEALTH r 30
Vital Records Section Burial - Transit Permit
Name First \� r Middle �n QY� Last � Sex /�
J 1_` 0��0.ZZ_C7 1"1
Date of Death apt Age _ If Veteran of U.S. Armed Forces,
..:. 45 O `�" `J War or Dates
Death � n
C own illage G\ems ' .a '\S Street Address or
ens 50 s 'Aos p 14-a)
annex of Death mai Natural Cause D Accident El Homicide El Suicide riUndetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Ki rc e ceS C bn\l;v-,9eY phys;0 an
Address fA,E&OaY-d + V +n,qSIX"(1 114&04Arl rj?, r
Death Certificate Filed District Number Register Number
, : Town or Village �)e✓LS Fa)1 S :56 Q/ c).2V
Date 1 Cemetery or Crematory
ii LJ Burial 05 I D? J- .o)`I Pine_ \) 1 e t,J rrern OA-fl r y
Address /,
ii LCremation (.Yv.f.ers xry I )�• 1Z3O
Date / Place Removed
8 Removal and/or Held
i* and/or Address _ ___
a Hold
0 Date I Point of
i.
ca Q Transportation j Shipment
4 by Common Destination
Carrier
_ Q Disinterment Date Cemetery Address
Reintermeni Date Cemetery Address
Permit Issued to Registration Number
; Name of Funeral Home H nard b, ma Funeral neral Horne__ 01130
": Address /l tC Qr V
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
le Address
x>:
Permission is hereby granted to dispose of the human r ains d "bed aboy as Ind' ed.
y .
Date Issued 05/0(1/col y Registrar of Vital Statistics L�-�_-- i 4
(sign e)
Y.: District Number Sia O I Place c2_-�
I certify that the remains of the decedent identified above were disposed of in accordance this permit on:
F
Z
Date of Disposition Place of Disposition
(address)
SA
CC (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises
Z (please print)
• Signature Title
(over)
DOH-1555 (9/98)