Barenco, Rose f g Gill
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name first Middle Last je
Qom- _ 1C 0 .�
Date of D ath A e
if Veteran of U.S. Ar ed Forces,
/ ' -0-0 j j , 9`? a War or Dates .
Place of Death i Hospital, Institution or
City. Town o I ak,11S n 4 Street Address Marie 0004 A40,-/t.zir-
ettManner of Deat Natural Cause Accident Homicide Suicide' Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
fl S1 r6L1 r ❑__
Ad ss
v-77U11---.41--
Death Certific. • .ed 'strict Nu ber Register Number
.;: City, Town . Village p � � j\ 4a...
1 �'`�
:. e etery or remator
El Burial -77:17_,Thl
Addr ss 5Z3 Cremation i 0 tital.51,3t�
Date TiPlaceReoved
0❑Removal and/or Held
and/or
Address
N- Hold
Date Point of
N❑Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date - Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to .-—. Registration Number
`- Name of Funeral Home 1*�
.-- , ul t i r C_ ooa J I [
Address
'''• c94 auxchsL _
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped. If Other than Above
11M Address
,W
Permission is h reby granted to dispose of the human remains crib above as indicated.
Date Issued d Registrar of Vital Statistics
(signature)
District Number ?30(() Place 4 a IiSir'7 5P°---
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t"- (� l � 7
WDate of Disposition 7-ih-l3 Place of Disposition +,r G iwwst'or w-
2 (address)
W
N
EC (section) (lot mber) (grave number)
GName of Sexton or Person jn Charge of Pr mises r .- c,� "h
Z (please print)
f� Signature Cp Title CeeN►A r
DOH-1555 (10/89) p. 1 of 2 VS-61