Picioccio, Dominc NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mi e Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address 7- fAhe
Manner of Death pENatural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
iL
Address
p
Death Certificate Filed c� District umber Register Number
City, Town or Village
t
Date Q'ry o remator
❑Burial /S Lee",)
<: E&cremation Address
Date lace Rem d
❑Removal and/or Held
r. and/or Address
Hold
Eh
Q Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home 5&41X� X�/4�
'>> Address
Name of Funeral Firm Making Disposition or to horn �v
Remains are Shipped, If Other than Above
Address
Permission is her by:g anted to dispose of the huma mains described bove as indicated.
Date Issued 1�- Registrar of-Vital Statistics
si nature
District Number Place
I certify that the remains of the decedent identified above were disposed of in accorda` e with this permit on:
W. Date of Disposition Place of Disposition
(address)
M (section) lot u er) (grave number)
Name of Sexton r Perso in Charge of Pr mises
(please print)
Signature Title ll `
DOH-1555 (10/89) p. 1 of 2 VS-61