Mangiardi, Patricia NEW YORK STATE DEPARTMENT OF HEALTH b0
Vital Records Section Burial - Transit Permit
Name ice.. Middle Last Sex
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Date of Death Age If Veteran of U.S. Armed Forces,
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E4 Place o Death — r Hospital, Institution or
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Manner of Death 'Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
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iiiiiii Death -•. icate Filed District Number / Register u ber
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❑Burial Date,/ C etery or Crem/a jory
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Date t Place Removed
Z Removal and/or Held
Co* ❑and/or Address
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to
0 Date Point of
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to ❑Transportation Shipment
0 by Common Destination
iiiiil Carrier
El Disinterment Date Cemetery Address
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QReinterment Date . Cemetery Address
Permit Issued to Registration Number
iin Name of Funeral Home Sw/a 4 L, I. rV IIJenc ( / - ar'- --t lis
iiin Address 1
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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 hereby granted to dispose of the human remain escribed above a ' dicated.
Date Issued kV/ar/i/2— Registrar of Vital Statistics ,dr
(-' (-gn. ure)
ii District Number /�lpz/ Place i iA C0 d 0 v,66h, A-V '
iL I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition /O ii3 JI Z Place of Disposition -,d U tt,u oforI,.�_
2 (address)
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CC
(section) y (lot number (grave number)
p Name of Sexton or Person in Charge f Premises L�hs Q fr"
11(1) (please print)
14
Signature Title corm/io6
(over)
DOH-1555 (02/2004)