Sisti, Patrick NEW YORK STATE DEPARTMENT OF HEALTH A. S,,s
Vital Records Section - Burial - Transit Permit
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Date of Death Age If Veteran of U.S. Armed Forces,
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Place • Death Hospital, Institution or 0 /pile,'
W City,' . , • '�r Village a ia-ru- street-Address I ra/ .0.c
0 Manner of Death INNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
lij Circumstances Investigation
to Medical Certifier Name Title
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Address � 3
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Death Certificate Fileak District Number Register umber
City, os oxjyr r Village i C)J') C-t&U-� ) 1,L.p Lp 1
❑Burial Date I o/4 ► 0-- Ce etery or/Cremate, _ 1
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❑Entombment Address /
Cremation Uet-i bllrL< Ai ' ,01. '0`f
Date J Place Removed
Z❑Removal and/or Held
2 and/or Address
H Hold
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O Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home , A ) I )e - :•' % 1-bynL., 01 I g I
Address
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Name of Funeral Firm Making Disposition or to Whom
} Remains are Shipped, If Other than Above
2 Address
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Permission is her by granted to dispose of the human re s described above
as indicated.
Date Issued 1 0 5 1 `� Registrar of Vital Statistics (JG O�( :.L.-
(signature)
District Number I (o ,(2 Place —ry �A �c._r \ c.` CA C,c c=-.__
certify that the remains of the decedent identified above were disposed of in
accordance with this permit on:
Ill Date of Disposition j 1c hi, Place of Disposition -EN,Vife.. C rry..tbniu�
2 (address)
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CC (section) 4,,,.„‘lot number) (grave number)
Name of Sexton or Person in Charg of Premises - n tt
z lease print)
W Signature Title C U ti --roini-
(over)
DOH-1555 (02/2004)