Bonsignore, Cornelia r411- VI -F 31,
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Trans t Permit
Name First Middle Last Sex
C'r:Y2Av,C1_ /A >z uni Qv�s ilr Iv v n-/' 1ia1 e_..
Date of Death r Age / If Veteran of U.S. Armed Forces,
/k-//4y .2" ' ... 6)/3 7S War or Dates
14 Place of ath Hospital, Institution or
111
Cit Town r Village ,Uogg ,E te..9 Street Address Alt/C - U!//L./0
W Manner of Death Natural Cause 0 Accident D Homicide 0 Suicide 0 Undetermined 0 Pending
Circumstances Investigation
U Medical Certifier Name Title
AVI `ioi-i,CNA H1 D
Ads
1/ /-S our /6/rQrz,y /24 4A/ j Ae.-46/D. by 125C4
Death C ficate Filed / District Number Register Number
City, ow r Village,(f0/Z%// /CAL, i.5-G0
EiBurial Date Cemetery or Crematory _
DEntombment ' " y 4 .2013 . /6//V�, l�7 t1 07,-/-14I dam/
Addr ss
Cremation ?/ A Ul9/<r L •/ Q Ueei'iSt O'S / my l . T t) y
Date Place Removed
22Z❑Removal and/or Held
and/or Address
L. Hold
{7
0 Date Point of
0 Transportation Shipment
L3 by Common Destination
Carrier
i 0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to � � Re istration Number
Name of Funeral Home. • � .//z. /AJC . auid 7S—
Address
c2 3/D s-iorZ.Arv/o(, AL' tw Paco Aly /22cVd
Name of Funeral Firm Making Disposition or to Whim /
J. Remains are Shipped, If Other than Above
,'; Address
CC
it/
Permission is hereby granted to dispose of the human re ir�s deTisibedbove as indicated.
Date Issued s'-Z,9,-/� Registrar of Vital Statistics r
/ (signature
i> District Number`S6SO Place TWA) ex-- /Clon.;;< /zLd24
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ft! Date of Disposition S.130113 Place of Disposition 4712/41)t roc r7ri.‘.-
Ltif
(address)
to
ix (section)( ) (lot ber) (grave number)
Name of Sexton or Pers in Charge of Premises a0-31a p�.n/�-
(please print)
114
Signature iL.. �,G.�' Title CrocilWrOYI-
(over)
DOH-1555 (02/2004)