Caselli, Richard r IV 4 117
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
r r Name First Middle Last( D1 Sex ,N
Date of Death Age
If Veteran of U.S.Armed Forces,
A. 1 7, 19 1Zo'3 bC War or Dates 1TS.:-S- 1\SCP
-''' Place of Death Hospital, Institution or G rn v.L t e
'F. City, Town or Village Street Address 15 COL''\( eouk so N-f,,,,3Z
Manner of Death won Natural Cause ID Accident El Homicide El Suicide D Undetermined �Pending
Circumstances Investigation
r Medical Certifier Name Title
• Door�., - C,a;O1-- Gr,,),,,Neks M�
s Address
,4 1 DI' Par\(-• S}-rem- ClteeN S Pca\\S, ),Yi 17SO\
Death Certificate Filed District Number Register Number
City,Town or Village C ra n\J , 1\t_
Date Cemetery or Crematory
:i El Burial 1.3,1 17 ) 2-•01S Pine_ V V . Crremccaocl
Address
. • El Cremation c enSb t,.r,-1 i /6
Date Place Removed
fl❑Removal and/or Held
M and/or Address
55 Hold
Date Point of
Q Transportation Shipment
a by Common Destination
Carrier
.`i:i`Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to t f rr b, &tker FweccJ home Registration Oj0Number
�. Name of Funeral Home r!
Address
g.
// Larea.y_e,tte of. , ( u ezinbUr j ,New %Tit- l a gOy
',.A. Name of Funeral Firm Making Disposition or to Whom
{ Remains are Shipped, If Other than Above
.-. Address
Permission is h granted to dispose of the human 'ns escrii - . •ve as indicated.
Date Issued 1 a` 0�\ Registrar of Vital Statistics S ti ►`144C
' cit (signa�t(uree)) i
District Number 51 SCt Places \ r " t
I certify that the remains of the decedent identified above were disposed,of in accordanced with this permit on:
J Date of Disposition 1 a-i$-k3 Place of Disposition -(�„r•QVe� L n-act"d�--
(address)
IL
tk
CC (section) do
(lot umber)C (grave number)
QName of Sexton or Pers -n Chargeof Premises ) P- ►irtt
z (please print)
Signature d Title C+igirs7I W-,
(over)
DOH-1555 (9/98)