Bisetti, Adolph NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics-Vital Records Section
Name First Middle Last Sex
Ad
Bicett ......::::..........::::::::::::::::::;::::MaJ
Date of Death Age If Veteran of U.S.Armed Forces,
May.10.....:1990...............::.::::.................::...... 87 ,::,::::.::::,..>::::::War or Dates............... .................................................
Place of Death Hospital, Institution or
City,Town or village
:.........:......::::::.::::::::. ..................Tic:.oneroa ::. Street:Address ose::.s: Ludington Hospital
::::: .... : .....:::::::.::: .... P .. ............................
Cause of Death
' ventricular lachycardia
C :::::...........::::::::.:.::::......::::::::::::......::::::::::::.:::::::::::::::::::::::.,:::::::::::::::::::::::............ ::.......::::::::...::::::::::::::::::::::::::.:::::::..................................
Medical Certifier Name Title
.... .................................... .Guy..G danoM:D::::::::::::::.::::::::::.::::::............................................................ .....
.....................................
>..............................................:Aadress
Wicker St. Ticonderoga, New York
::>............:.....::.::......::::::::::::.:......::,:.:::::::::::,:::.::::._::::::::....:.:.::::::::::::::.::.::: .:............::::::::::::::.:.:.....:.:................................................................................................
Death Certificate Filed District Number................................................: Register Number
City,Town or Village 1564
Date Cemetery or Crematory
❑Burial .... ........� y::
[aCremation Addressll..._1990 Pine View Crematory
.......::.........::::::..:...................:::::..:.....::.:....:.:.::::.:.::.:::
r Road ensb New York 12804
.::..............Vie...............:..:::..:4 .......:.::: ',..:::.....:::......::::::....................:.:.............:......:.:.:....:...::...............:......
Z Date Place Removed
Q ❑ Removal and/or Held
and/or Hold ............:::::::::......:......:::;;::::,::::::::::::::::::::::::::::......:.................::::::::::........... ::......:::::::::::::::::::::::::::::::::::::::::::::::::,:::::
Address
O> ::::::.:._.;:::.:.::::::::::.:::::::::::::::...:::,::::::::::.::::::::.::::::::.:.::::::::::::::::::::,::::.:_.::::.:::::...............__.........._... ...... ........_........._.........
�. Date Point of
w: []Transportation by.. Shipment
OCommon Carrier ..............,..................................................................................................................................................................................
Destination
..................::::::...::..:.:::..........::...:...:::...:.......................::::.:.................:.:::.:.......:.......... .................. . .. ...::::....:.....................::.........:.. ::.::...,.::
❑ Disinterment Date Cemetery Address
::..........:::..................................:::::::::.....::::... :... .............................................................ry................... . ......
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
>< Name of Funeral Firm Wilcox..&..Regan Feral Hoare 02133
....::.......................
Address ......................................................................................................................................
.....................
33. Algonkin. St.....Ticonderoga. New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Z.
Permission Is hereby granted to dispose of the human rernalnn described area as indicated.
Date Issued Mq)E l_1 1990 Registrar of Vital Statistics
(signature)
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with thiissA permit on:
r
Date of Disposition r Place of Disposition /y//� �/�� �' i0c.
(address)
wr
(section) (lot number) (grave number)
p` Name of Sexton r Person i Charge of Pre ises
Z' (please print) ,p ! '7"-
�; Signature Title G /�J/` ��
DOH-1555(9/86)p 1 of 2(formerly VS-61)