Lupo, Donna NEW YORK STATE DEPARTMENT OF HEALTH 1 f b
Vital Records Section Burial - Transit Permit
11 Name . First Middle Last Sex
\oY\no, ) 1v ( ca `�
Date ofclgath Age If Veteran of U.S. Armed Forces,
1 -] - 9,0 1 , 5 O War or Dates
Place of Death Hospital, Institution or
City, Town or Village F�S.s 1CQ_ 1�U 7 y s� Street Address
Manner of Death ry,Natural Cause 0 Accident ❑Homicide 0 Suicide ri Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Pa L B �cI,`n..a". /'Ab
ai Address
Death ificate Filed District Nfamber e Register Number
iiiiiii$ Ci , Town r Village Lam/ /-�crne—. 5-�6 S- i
Date Cemetery or rematory
❑Burial L / 3 /), v t , \n z v C /.. tik r
Address
NCremation kA- ,,56.� w v
Date Place Remove&ri❑Removal and/or Held
and/or Address
g Hold
0 Date Point of
NQ Transportation Shipment
5 by Common Destination
Carrier
•:: Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiiiii Permit Issued to -- // Registration Number
€' Name of Funeral Home ��� i1j)(/�� c. 1 ��f d-Yrcc� G Q 4-`{
Address
7 . ma c, �� dv.,,L`ri Aiy id- '; -
:,:: : Name of Funeral Firm Making Disposition or to Whom
iit Remains are Shipped, If Other than Above _
Address
ILI
iiiiiiii Permission is hereby granted to dispose of the huma r ains de ribed ab el.'s indicated.
iiiil Date Issued /- o(- 2 '3 Registrar of Vital Statistic c4 �4 G71M-ei) 7
(s. nature)
District Number o_D /,
Place /a 4_iia
4UZ.-E�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition / 1-I) Place of Disposition AZ 0144) f lg ..>
2 (address)
il:l
CD
CC (section) A (lot-number) S (grave number)
0 Name of Sexton or Person in Charge of Premises A r,,tr/ t+q �'
Z �ii (please print) l
Signature f 1�., Title C 1i
I
(over)
DOH-1555 (9/98)