Bonavita, Beverly r I
IT
NEW YORK STATE DEPARTMENT OF HEALTH �(4
Vital Records Section Burial - Transit Permit
Name Fir nliddle Last . Se�js��---
Date of Death Age If Veteran of U.S. Armed Forces,
oer- War or Dates
1- 'Place f D7th Hospital, Institution or
City, ow or Village A r r,,, Street Address ,tikty
ner of Death 3 Natural Ca e pcci nt Homicide Suicide Und rmined Pending
UCircumstances Investigation
ILI Medical Certifier Nanile Title
Address 02)k mot EL J\/ r,� y`f Al /. 0y
Death Certificate Filed District b4umber Register Numb
;Town or Village • • SARATOGA SPRINGS50/
❑Burial Date S / Cemetery or Crematory
DEntombment / I al 3 iL►ev,-C. w do .., r
Address /
[jIremationa LA C c A ,..,‘fj ) Ne --a /..),i‘'
`'
Date Place Removed
Removal and/or Held
C ❑and/or Address
F` Hold
0 Date Point of
Transportation 0 P Shipment
el by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home /tc'll,re :Acr.s1 0-1.,,7 __ �j.* 1.7.Si
Address
>` Name of Funeral Firm Ifilakin Disp
osition p ositio n oY to Whom
Remains are Shipped, If Other than Above
2 Address
CC
LAI
"` Permission is hereby granted to dispose of the human remain ib aboyr a ' dicated
Date Issued c/7 ,i> Registrar of Vital Statistics
(signature)
District Number l/j-( / Place SARATOaA CPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 6-413 Place of Disposition 1.,,,, r-t„r.,
(address)
In
V)
IX (section) (1 umber) /" (grave number)
ita Name of Sexton or Pers n in Charge of Premises l "',) JtlikeIt
(please p nt)
Signature L Title CAENi t)C
(over)
DOH-1555 (02/2004)