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Mondella, Joseph NEW YORK STATE DEPARTMENT OF HEALTH t " % i 5 3) Vital Records Section Burial - Transit Permit tili Name First Middl Last Sex `-Cc'se �c�n via +ems /9/0ne/4114 f 1 i Date of Death Age If Veteran of U.S.Armed Forces, gi 7 o'-9—)u)-L p � War or Dates (iv LOT' _ Place of Death Hospital, Institution or City,Town or Village-7:w►, ( b Street Address Ai-- r) k : Manner of Death©Natural Cause Accident Homicide 0 Suicide Undetermined Pending Circumstances Investigation_ • Medical Certifier Name • Title C. �v i i . o hi —Fed.es h D gv Address o3 ' c„ — Lit C Death Certificate Filed District Number Register Number in `' City, Town or Village (4 e( .al C j i•-k _ 15'e)c") /?'7 Date Ceme,ery or Crematory 0 Burial /U—f a "Z EJ r ()F 0 w (�7LL f& celfil- L Address • (l'Cremation _ CO U d ��. . .... . Date Place Removed Z❑Removal • and/or Held tt, and/or Address - Hold • 5 Date Point of 0 Transportation Shipment a by Common Destination Carrier ; : Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number a>' Name of Funeral Home m k) @L,t. () t 12�. OA? b ibi Address „.„ . 1 I L4 tlf---i C4* C-0,4113 6)/ ___ 14_,fr il Name of Funeral Firm Making Disposition or to.Whom / "" Remains are Shipped, If Other than Above CAddress • • 4 - "` Permission is hereby granted to dispose of the human rem ns described abov as indicated. iit Date Issued PO'/ .-- 1/1 Registrar of Vital Statistics (signa ure) €'`} District Number 51,,S--) Place • F- I certify that the remains of the decedent identified Move were disposed of in accordance with this permit on: Zi iti Date of Disposition ID I it lit Place of Disposition 2it(AMP Cwmc¢ri;ir..N, . (address) co • tx (section) -(lot number (grave number) 4 Name of Sexton or Person in Charg f Premises r,Yt N-. (please print) Signature7/11.. Title .at M►-T Orl. (over) DOH-1555 (9/98)