Petrillo, Marion NEW YORK STATE DEPARTMENT OF HEALTH - rm it
Vital Records Section Burial - Transte
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
Z N J O\3 (S D War or Dates N , A
541.1 Place of Death Hospital, Institution or
• or Village a�.Q.'(\S �a\\S Street Address Glens i -Q\ S t►-! .k I
• Manner of Death[Natural Cause 0 Accident El Homicide 0 Suicide D Undetermined '- ding
., Circumstances Investigation
ii,:;• Medical Certifier Name /� Title
g Day-6e,a O-v ` GrtiVb5 M\D
il Address
U Z 'A r 1- S -e-e 4- CA—ens a\\S I }\) 1Z 501
su: Death Certificate Filed _ District Number Register Num Der
1$7; , or Village 1\c&j ct\\s Deo I _ 5Iy
Date Cemetery or Crematory
0 Burial \Z l9 ' ZO\3 )vn� ,ev.) C_rerc.oa\-Orj
Address
54Cremation au,Q.0 Sb U r N\I 1 Z 3 0 1
Date I Place Removed
a
0 Removal and/or Held
and/or Address
I Hold
d Date -Paint of
`�Q Transportation I Shipment
• by Common —Destination-
.:.
Carrier
Disinterment Date Cemetery Address
0
Reinterment Date Cemetery Address
VI Permit Issued to imp Registration Number
Haynard b. 'Baker Funeral
;��; Name of Funeral Home On��
Address
il 11 Lana ydte . , ( uee.nsbun i/Jew JorX l affUy
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
r,. Address
Permission is hereby granted to dispose of the human remains d ibed a ve.2�v
icated.
kN �Date Issued /�`4���7/� Registrar of Vital Statistics �,'�
Ms
(signature)
District Number 5 7O/ Place Veovo ,//A., /t/Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.1 Date of Disposition 11-1-13 Place of Disposition 'lint NV id',•_
(address)
•■ (section) 4(lotirber) ((� (grave number)
Name of Sexton or Pers in Charge f Premises c:si �X.,nes?fe rint
g.
(Ply print)
Signature Title 4 fi iiii-li ,
(over)
DOH-1555 (9/98)