Diaz, Linda NEW YORK STATE DEPARTMENT OF HEALA -AV'
Vital Records Section Burial - Transit Permit
fjg Name First Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
0 gj Pt 13,0 vN 5"`\ War or Dates —
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t,.,.. Place of Death Hospital, Institution or
uig City, Town or Village c.c•-c...kay.. Six", 5 Street Address S c..i—c.A.0 y, kkoS i..1 LI
a: Manner of Death Natural Cause El Accident El Homicide 0 Suicide Ei Undetermined ri Pending
ttj Circumstances 'Investigation
t2 Medical Certifier
Name is, Title iN 0
CI (- sko \.‘tLc .t Y
II Address
Mi 'g•lk CA\,, r-L L ...S1 S c.,- . k-00,. &v-:-, s IN/ 1
I Death Certificate Filed District Number . Plegister Number
al City, Town or Village li SO I 91/
.:.:- Date Cemetery or Crematory
.i. El Burial a/al I 13
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"•-•:
:•:-. Address
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.... w-A-:• IX!Cremation G.- --V-Lf- ‘ .(n.c_a QL)ct,,,NA,„ NkA t .z0L-1
.....
.....
--- Date Place Removed r--x
Z=Removal
0 1--I and/or Held
r: and/or Address
f•-- Hold
2 Date Point of
ir)1:1 Transportation Shipment
5 by Common Destination
Carrier
-:•:. _ Date Cemetery Address
i Li Disinterment
Date Cemetery Address
i:i:: ii Reinterment
.:_:.
a Permit Issued to Registration Number
gi• Name of Funeral Home/e-.1N%CYNC).r.c._ 2‘,.e_1,A kko vvve- c.)0'-kWg
2.,
Address (
\--Jur kg — k
4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
.x
W: Permission is h reb granted to dispose of the human rema* ..) ()described above as indicated.
:
M- Date Issued -2. ' Registrar of Vital Statistics T.
is SONIA VOOL'' ''M -r•N' '\
NI District Number ‘--1S-CD1 Place
*: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ei Date of Disposition i.-2(-(1 Place of Disposition -0401.4.0i C•446--
m (address)
fa
011
(section)g lot nieber) . , (grave number)Name of Sexton or Person in Charge of Premises hro L.,
0
Z (please print)
LU Signature ditL_ sp_. Title Cedilpost„
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(over)
DOH-1555 (9/98)