LaCatena, Martin NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial ® Transit Permit
=€ Name First Middle 11ast Sex
== /7 Orz n ) Po- S C“.)6- e- (—e--c e-r—b-Ai ya-- ji 6'z i:.
Date of De h Age ,_ If Veteran of U.S. Armed Forc ,
/2.3 J/P i e 7'7 War or Dates ,,J/id-
Place r ath Ho •. - .stitution or
Z Ci' ,gown` r Village
e Q 0 t �J-S g Street Address q co rL C..43 v 114"
l Manner of Death Natural Cause 0 Ac'dent n Homicide n Suicide Undetermined n Pending
I Circumstances Investigation
W Medical Certifier Name / Title
CII$6,
A() ' LCV L ii
Address
Death C'a " icate Filed District Number �S� Register Number
City, TowAr Village g U nay
ui
>`0 Burial 1 Date / Cemetery(Cremat r ) i
[]Entombment! `P 2-Y I /".) t-- (f I ��-J
Address
remation ,) u -i L, - 1,2
4.3 a U r✓ -s es U 0_,y I v
Date / Place Removed /7
t Removal and/or Held
� and/or Address
cii Hold
0 Date Point of
iik C Transportation f Shipment
a by Common Destination
Carrier
:`'.Q Disinterment I Date Cemetery Address
Q Reinterment Date I Cemetery Address
•ikPermit Issued to i_� Registration Number
Name of Funeral Home t .\i'V:._ " ;1L:z1\ \-'\0 1 C-t 1 O
Address
1l t.._cSa,{c.V- �-,- Cam:: c:\- s�� i i 1Ly 1 G y
Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped, If Other than Above
Address
tr.
tia
rL
Permission is hereby granted to dispose of the human remai rib
ve dicated.
Date Issued a -(g Registrar of Vital Statistics
(signature)
District Number 5(61 Place 4'0 US\A (_ 14
I certify that the remains of the decedent identified above w disposed of in accordan ell ith this permit on:
E
iLI Date of Disposition-d.c(-t g Place of Disposition ?i At V\'c W L Lz, c4I-ccy
(address)
to
b
. (section) (lot number) (grave number)
La▪ Name of Sexton or Person in Charge of Premises .Tt NI-UV c t.s
(please print)
14 .Signature
Title C,fc.mcl-1c.r
(over)
-
DOH-1555 (02/2004)