Mammina, Veronica NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .1 Burial - Transit ermit
Name First - Middle Last Sex
lie f 00 r (.c M ck 04 IAA. t tA,0._ Ce AR GO e
Date of Death e If Veteran of U.S. Armed Forces,
--
6 — / 3 /3 A // War or Dates NQ
Place of Death Hospital, Institution or r '
City, Town or Village .5a( 5, Street Address S�o� /40Sprk(
111
Manner of Death IC71 Natural Cause E Accident ❑Homicide El Suicide ElUn ed termined ❑Pending
W. l� Circumstances Investigation
W Medical Certifier Name Title 0cc "oGer ci�dl
• Addre s
Death Certificate Filed
District 1Vumber Register Number
:fflCi Town or Village SARATOGA SPRINGS
❑Burial Date r —
I _ CemetRry C remq r . i 6r-ex�etio r
❑Entombment Address G (�a' vl o W
;;Cremation Z( Nct4. Lk ue A S bar �Y 1 2eG
Date . Place Rem ed
Z ❑Removal and/or Held
1 and/or Address
I= Hold
Cl)
0 Date Point of
D"0 Transportation • Shipment
0 by Common Destination
Mi Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to r Registration.Number
Name of Funeral Home L 1'l t 5 rG A 0.-.i-es woe, ( � vU 3 6 II
Address
1/02 ekt Note, 4vc -S _ Pr i 28G-6
Name of Funeral Firm Making Dispo ition or to Whom
1,4 Remains are Shipped, If Other than Above
Address
#c
t:
ix
Permission is hereby granted to dispose of the human remains d ' ed bove`P
indicated.
Miii Date Issued f /4; Registrar of Vital Statistics
/ / (signature)
District Number 45-0/ Place SA , TOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Ill Date of Disposition (0-(7-t5 Place of Disposition R„�(��,„� etwicA�..
(address)
itil
tn
CC (section) - (lot number) (grave number)
Name of Sexton or Perso in Charge o Premises %Ji ._ Pam'
2 (please print
ill
Signature IL--
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(over)
DOH-1555 (02/2004)