Anunziato, Claire ft
NEW YORK STATE DEPARTMENT OF HEALTH s 1 �S-3
Vital Records Section Burial - Transit Permit
«-' Name First 1 s Middle Last Sex _
Date of Death Age If Veteran of U.S.Armed Forces,
q fi g b.3 13 War or Dates
Place of Death `` r Hospital nstituti br ,-
City,Town or Village Fob-A- t-C 3 QkrC Street A ress /-o 4 �7 Ad Sxj\ii
Manner of Deathc®'Natural Came El Accident 0 Homicide El Suicide �Undetermined Pending
rki Circumstances Investigation
Medical Certifier Name / Title
64/�G,,.,1 41
Addr �n ))
7(c,,.r....7 /` c. O�ts2vise 1 ,/b/V /o FOl
_ Death Certificate Filed iD _ District Numbe j Register Number
City,Town or Village►-f 0,7 vV - ` j 2,j 6-
El Burial Date Cemetery or Crematory
' ❑Enfombmenf 0 9-/4-/3 z�/v/ e, / /€ A) C.✓P,.,n,--- , y
Address��jj / j� / ,,/
;! remation O vN e.r .0 l ( cn P),i S b N ✓V 1 ,,,C,,
(/
Date Place Removed I
❑Removal and/or Held
and/or Address
Hold
Date Point of
w,,,rn
Transportation Shipment
by Common Destination
Carrier
."r �Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Hay f and •Zakef Funeral( Homy- oil o
Address 11. Lafa e-I--fie_ Sireet Queensbur
y y , Nevv yor- lc Iagoy
Name of Funeral Firm Making Disposition or to Whom
1., Remains are Shipped, If Other than Above
Addrass
:��pdpeegg6}}C
Permission is hereby granted to dispose of the human re ins describ abo as indicated.
Date Issued9-/9-6 Registrar of Vital Statis i
—__,____ (signatur
.: District Numbers Place
`: I certify that the remains of the decedent idea- d above were disposed of in accordance with this permit on:
DT Date of Disposition '1j jOi3 Place of Disposition es04/ 1 CrtA-ctoriv—
?- (address)
1711
t s e, (section) pot number) 7 (grave number)
Name of Sexton or Person in Charge Premises
i, r/ ?rrfl�}
( print)
iTri
::> Signature
Title rak 'Iit
(over)
DOH-1555 (02/2004)