Sigismondi, Nickolas NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle . . Last Seri„
rf$': Date of Death . Age If Veteran of U.S. Wed Forces,
fir. 1 j / 1 /t3 �13 War or Dates •
''' - of Death r Hospital, Institution or
A. City, own or Village 6L> F t 1 I S— Street Address '�is ql L,. l'"
a. er of Death ri Natural Cause 0 Accident Homicide 0Suicide 7 Undetermined —' Pending
�#- Circumstances — Investigation
Medical Certifier Name ii jj Title
tl1 t�,.� ��r+.� h�3L M j�
Address .-,
d b r//\ u Pa }}-- /r • (3Le-ram f`�t� / J1/41 1 f
. f 1 Di
`:r •-__-th Certificate ed ��� �_��- District,Number i Register Number I
::11:pliggp, Town or Village .) 60
Date / Ceme or Crematory
❑Burial 1 H / 2) . 113 ,he v:c re--t.A--r
Address l.
. Cremation .c.e As bv. • /•r tr(.
Date 7 Place Removed
2 Removal `
O and/or Held—and/or
�:., Address
Hold
Cp Date Point of
N0 Transportation Shipment
Q by Common Destination
Carrier
Disinterment
Date Cemetery Address
•
Reinterment Date Cemetery Address
Permit Issued to Registration Number
y Name of Funeral Home e s,,.lo rt I :.: 1 e td. �'-yr _ 6° `�g-1s
0'` Address I '�
7
>, / /
vg
•5� Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address -
go
sii Permission Is hereby ranted to dispose of the human remains described above s in at d.
Date Issued 1\ 'ate /3 Registrar of Vital Statistics />
:::: C (si nature)
jiiii.iwDistrict Number J -00/ Place . /s" Il S'� ,�e 1 Y i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
E Date of Disposition 1 fr u1 t3 Place of Disposition Z +,—/ ( 4o'*—
(address)
Lii
cc • (section) (I num er) (�� (grave number)
0 Name of Sexton or Person in Charge of Premises ,,,fi 310,4 14-
2 (please print)
W Signature Title CriAitiTC
(over)
DOH-1555 (9/98)