Rossi, Germain NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name �ea
Middle Last �e�x
.::.::. . ...... ... ..
_ ,���,p .:...
g
Date A e If Veteran of U.Sf rm'imces,
War or Dates
!-- �_3.::::::.. _ ..::.::. ��iD ....... ...
Place of D ath Hospital Institution
1U. City Town or Village Street Address
............ ..
0; Manner of Death Natural Cause Accident[ Homicide:........:: ici...e. ....... . ndete fined ....::. Pending
W Circumstances Investigation
f3 :: _ .: . ... ..................` .:.::::::.
W
M cal Certifier j7e Title
A ss
...: , ...G�,....... ............ .....: G !� :.... ..:. .:: . . :::.. ...: .. . ..:.:. ::. .: ::::....:::
D ae�th Certifi a Filed Qistnct Number/ Register Number
City,Town or Village
D Ce etery r ry
❑Burial `j
anonAd S a , /
Z Date Place Removed
O, ❑ Removal and/or Held
H and/or Hold ..:....: ....:.::.... ..:.. :,..
Address
tn:
O............................. ............................ -...........................................
IL Date Point of
cn; ❑Transportation by Shipment
p Common Carrier .................................. ......... ..........
Destination
. . ..............................................................................................................................................................................................................................................................................
❑ Disinterment
Date Cemetery Address
_ _ _ .......... _ _ _ __._ _ _ _ ...
.......................................................................................................................................................................................................................................................................
❑ Reinterment Date Cemetery Address
Permit Issued to / Registration Number
Name of Funeral Firm r ��a �4��'
_ .:�: : .:: .....__ saw a G/ U 3
Adddres i
Name
uner ::.. .ki: :::Isti or
......a .v: : to Who m . . .. ...........
2. Remains are Shipped, If Other than Above
..... _ .............::.......... ... ........ .. .......::..Address
u>
Permission is hereby granted to dispose of the humr remains' d Cr�Oqd a ve as indicated.
Date Issued ��� Registrar of Vital Statistics
(signature)
District Number Place
certify that the remains of the decedent identified above were disposed of in Lac� ance with this permit on:
W: Date of Disposition s-9� Place of Disposition /yi4 /L.`'!� ��j,L�/��lo�/d1*1
2 (address)
ul
X (section) (lot number) (grave number)
p' Name of Sexton or erson in harge of yPreises
Z (please print)
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61