DeLeonardo, Frank NEW YORK STATE DEPARTMENT OF HEALTH 11.1/
Vital Records Section Burial - Transit mit
Name Fir t —7Th Middle Last Se /,,
NI - . -67/-eGV-1 rc--17e,
ni Date of eath
Age / If Veteran of U.S. Armed Forces,
11 A / 11 U ^ �� /- . War or Dates
f4 Plac eath' Hospital, Institution or �/'
:+' Cit , Tow 'or Village %PC'C7`� ; Street Address PGo� roie4
Manner of Death�-Natural Cause Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
Medical Certifier Namur Title u.
o ,��f />/�G . z��T
Address �y ,,r/ 4Z . /7/-)-fic-r-
iM
Death Ce icate Filed /� District Number Register Number
iiN City, o Village.�lG-G-7C 6;7-, 5p52/ 7
Date Cometef r or Crema/ory /1 ,-� . '
❑Burial �v G /��p�7 /`i--a L/( e� ( /��1c'r/0c/ 6/I--r
Address /, k.,"!remation Uri �/7` C:X(„iy-�'-p2re �G _ ,C �/
.. Date Place Removed 7
0 ❑Removal and/or Held
>E= and/or Address
Hold
0 i Date + Point of
fill Q Transportation 1 Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to ' Registration Number
Name of Funeral Hom Q��j'Qyj C�d� � � Qc /
`:>: Addres�j
)7-• 5 I - c76,C.-v."2 _//,/ 2,2ff/ ' ---
Na e of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
al Address .
''.> Permission is hereby granted to dispose of the human remai s described abov as indi ed.
i0 Date Issued 2 /3-/3 Registrar of Vital Statistics �� 6,�� �-
",,/ (sf nature)
District Number , ,--521" Place cyu'�,--...
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-
WDate of Disposition __ JlISJi3 Place of Disposition P 4w Civwcc{n,,,.
W (address)
Cl)
Gcc (section) {lot number) (grave number)
Name of Sexton or Person . Charge of P emises c.,1 ,. Sra„.,i,
F (please print)
44 Signature Title CIIZitijtI O(Z
(over)
DOH-1555 (9/98)