Carvajal, Ann NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Nam Firs Middle Last , Sex
n LP r ra n-e� Ca. �-v ek a. I vyia le
Date of Death Age If Veteran of U.S. Arme�Forces,
)(.; - 1 a- - oO 13 as War or Dates m c7
1: Place of Death Hospital, Institution or
Z City, ow or Village flQa(�.ki Street Address Z 7 L 1 n (<5 A'r
ui
Manner of Death®Natural Cause 0 Accident 0 Homicide ❑Suicide 0 Undetermined ri Pending
Ili Circumstances Investigation
WMedical Certifier ci Name Tale
I.L,sc -�-(ex\.I e5 M as a_ LP ro vK'_r
Address
5-7cl rally j a A& ' r i n s
Death Certificate Filed District Nurffber 1 Reg�i jter Number
City ow or Village-Had lexi 455 g 2S
io❑Burial Date etery or Cremato
['Entombment )2_ )3-20 I3 ► Y�c V i e�-c� �� YL
Address
'Cremation _k. but? j\y
ZDate lace Re oved
C3❑Removal nd/or Held
and/or
�;,;; Address
In
Hold
0: Date Point of
titi Transportation❑ p Shipment
5 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home -- f�,e ( .)._t,y_ /vic 00a 1 /
Address
a�- Q uU 1 St _ La. z..u. tx-ruZ, N y 1 Z€4 2-
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
Cr
la
C Permission is hereb granted to dispose of the human remaji,s described above ads indicated.
Date Issued la J 13 Z!3 Registrar of Vital Statistics �, & (. 7 4(
`(signature)
District Number .1.5,, Place T6L3v.\ op lad i
lei i
"' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
111 Date of Disposition la-l6-i3 Place of Disposition -6n��nw Coto(a-
a - (address)
111
co
1c (section) (lot number) (grave number)
Q
ta Name of Sexton or Person in C rge of Pre ises Ji 9, Si ,fir
z (piAase print)
Signature w Title Cliff)
/ L
/ (over)
DOH-1555 (02/2004)