Curcio, Theresa NEW YORK STATE DEPARTMENT OF HEALTH # Z(.2
Vital Records Section 0 Burial -Transit Permit
Name First Middle Last Sex
Theresa B. Curcio Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 1 , 2013 86 War or Dates N/A
Place of Death Hospital, Institution or
Town agailtsupc Somers Street Address 1 7 Jean Way
W Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tU Medical Certifier Name Title
o Harold Federman MD
Address
22 Wynnewood Rd, Chappaqua, NY 10514
Death Certificate Filed District Number Register Number
Gi#iwTown ainUtlicipc Somers 3-5, 4 ,o��
❑Burial Date Cemetery or Crematory
May 6, 2013 Pine View Crematory
El Entombment Address
[Cremation 21 quaker Rd, Oueensbury, NY
Date Place Removed
Z Removal and/or Held
42 and/or
1.-: Address
In
Hold
0 Date Point of
05 ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date - Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Joseph J. Smith Funeral Home, Inc. 00935
Address
692 Rte 6, Mahopac, NY 10541
Name of Funeral Firm Making Disposition or to Whom
104. Remains are Shipped, If Other than Above Miller Funeral HOme
2. Address
tr 6357 State Rte 30, Indian Lake, NY 12842
111
7 Permission is hereby granted to dispose of the human remains described above as indicated.
€< Date Issued 0,1--- 0,�,, ji Registrar of Vital Statistics ){ �
A _ - Q /
` (signature)
District Number S-94Z Place
` I certify that tha_remains of the decedent identified above wer disposed of in accordance with this permit on:
tit Date of D spp;tion r '5.-]a Place of Disposition R.40,...: �..rr•-ct,rwP_.
a _ (address)
ca - -
il - (section) (lot number (grave number)
A
3 Name of Sexton or Per n in Charge of remises . ` )�lrinf�
(please print)
41 Signature Title Ci% WO L
(over)
DOH-1555 (02/2004)