DeLauri, Francis NEW YORK STATE DEPARTMENT OF HEATH
3
Vital Records Section Burial - Transit Permit
Name First Middle st Sex
Date of Deaths' Ag If Veteran of U.S. Armed Forces,
�f 2�� --- War or Dates 31 7`�j - SI icy y 6i- Pie of Death Hospital, Institution or
` own r Village , t Ali buf Street Address L.e- � _ _ __
o Manner of Deathatural Cause El Accident 0 Homicide 0 Suicide El Undetermined ri Pending
fa
Circumstances Investigation
W Medical Certifier Name Title
CI --— _�>a-\-c ci G A-IA- � _ -- y sic (A.n_
Address
-11i-kA,W) ilfaLILIpCIA-trs W,__I 'N
th Certificate Filed' Dis t Number Register Number -
Cit Town or Village C I-& Fa l l-) j (9 Srm ) ) c /
❑Burial Date r j Cemetery remato , / t
1Q!l�� ) )3 --- �IIQ V i e.r' CeLY1 - ----
❑Entombment
Address '
cgt remation QUCi-e-r- .191,4walp_Gui4 NY i 2gO2-/
Removal
Place Removedz El
moval and/or Held
Q and/or Address --
(I) Hold
0 Date Point of
Q Transportation _ Shipment__
d by Common Destination Carrier
Disinterment Date I Cemetery Address
Reinterment Date _ Cemetery Address
Permit Issued to ( ` } 1 Registration Number
Name of Funeral Home 1 1G IlCc.i C) 6C kf=, g
Address f -
1 L.cl-1 Ci.V C 1 1 r: (�It c 1 ( , P\,c o 1( I ,), .S G
Name of Funeral Firm Making Disposition or to Whom -�
11-- Remains are Shipped, If Other than Above
Address - -__-
1X
W - - _.�._ --- - -- _-- __.
C. Permission is hereby granted to dispose of the huma remains described above as indicated.
Date Issued Intl)i / D., Registrar of Vital Statistics ! )�_ q .
(...) ,-,_,\:____
(signature)
District Number co 5--) Place ) r
.......„ _
i- I certify that the remains of the decedent identified above were disposed of in cordan e with this permit on:
2
ILI Date of Disposition 1i /11(3 Place of Disposition _ IN, y,.) ., P-�
W (address)
Cl)
CC 0 (section) (lot numberSt
(grave number)
Q Name of Sexton or Pers in Charg f Premises g
tI k
W , (please print)
Signature LC
g � ---- Title arzfreiVt, ---- --
(over)
DOH-1555 (02/2004)