Sabatelli, Eva it 177r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t_vc' &ba L� : f/�)a le-, -
Date of Death Age If Veteran of U.S. Armed Forces,
-�-O-i a ".7-t War or Dates No
Place of Death Hospital, Institution or
CI Town or Village r&1r l Slow i YJ 1 q`� Street Address �-F-dUndetet'mined
b ,�r(
.4 --
el Manner of Death Natural Cause Accident Homicide Suicide Pending
� Circumstances Investigation
w Medical Certifier Name Title
CI Dt S M.io v\A V t a C i_n M_ _.. —
Address
Death Certificate FileC i Di trict Number Register NuTper
, (COTown or Village t(�,- c ' 'r i ` ' 30 ( 5-7
Date 1 emetery or Crematory
❑Burial la to I (a Iii e Cerna r
��11 Address
Y�I Cremation i lea U eeil3bLLr NI��
ZDate i' 7 Place Removed
Z❑and/or Removal • and/or Held
Address
Hold
0 ' Date Point of
NQ Transportation ' Shipment
G by Common Destination
Carrier
0 Disinterment " Date i Cemetery Address
Reinterment f Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home R t.rt-e.x- i !" C wail
Address
c 4 e hu;c h 5t_ La Kc Lowry, t) l z$L
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped. If Other than Above
Address
11.
Permission is hereby granted to dispose of the human remai desc ib abdG>�a i dicated
Date Issued 1a a i I Registrar of Vital Statistics l
(signature)
I. District Number 4160 / Place ---a V.
77 n 4 (S / - /�/9 e/ j S
I certify that the remains of the decedent identified above were disposed of in ac ordance with this permit on:
i-W Date of Disposition Il-V4-R. Place of Disposition -FAt( rt j�
�ru-wdtoftu
2 (address)
W
CA
CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge f Premises 'ko J$n -
Z (please print)
W Signature i a Title Cetr,L,, O
OH-1555 (10/89) p. 1 of 2 VS-61