Damiani, Sylvester NEW YORK STATE DEPARTMENT OF HEALTH t L Z.
Vital Records Section Burial - Transit Permit
I
*Name First Miele- ,Last Sevii
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Date of Death Age p, If Veteran of U.S. Armed Forces,
7 -,-Z/ - oI ?j 6 W r or Dates
P -ce of Death Hospital, nstitution or
own or Village Lk- � _r ddress a
l�µ/ 1'
Uanner of Death Natural Cause El Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
19 Medical Certifier c. Name A Title
t f 1-1 I I- ) P C. A17,14, 0 b
Addres PI
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3 Z1Zo�rOUJ� ,� `� I✓ ,v I 4
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D--th Certificate Filed � District Number Register Number
";''Town or Village £ L . f' I�t_-t < 0/ 7 7
Date Cemry or Cre tory
❑Burial 2 -ZS-ZOi ) N_ V 1 ,,,J (A.L rii Prro Ry
Address
[O.-Cremation 7 ( QuIpt.VGiiR ret,. qvc...2)3s2",frzy M V I��I/
Date ce Removed
g❑Removal and/or Held
«•• and/or Address
k• Hold
0 Date I Point of
N❑Transportation I Shipment
5 by Common Destination
Carrier
::::: ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address:II
Ili Permit Issued to Registration Number
IIIIIIIIII Name of Funeral Home K L.vt,,f,lz �V RA,_ HO vti1- 0 l b-79
iii Address G G��D A-DtAA-/ CrDWdko /J '/ I'?i 2t
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>]� Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Iiig Address
CC
lA
A
ED Permission is hereby ranted to dispose of the human remains described boy as ii fy ted.
...` Date Issued 42 2)2 00-3 Registrar of Vital Statistics �
(signature)
<' District Number
J�Q/ Place t/I� _/���S', 4/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1rlb••0 Place of Disposition 4;,...'1/fa 6rw-c r+�
2 (address)
in
U3
CC (section) Aot nu ber) (grave number)
CName of Sexton or Person in Charge of Premises r,r}q ��,,-4
Z (please print) f
W Signature 41i, ATitle L olfrAl t-Df1L
(over)
DOH-1555 (9/98)