Tessino, Alison B NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First i D 1 Middle 8 Last -j—e S S i n0 Sex
N F
Date of Death Age If Veteran of U.S. Armed For es,
i �o
r' c -c bex ot(�z , aa3 S�l War or Dates '0\Pr
'ti Place of Death Cs S Hospital, Institution or � S l 1_
City, Town or Village 6-Auks F t Street Address tS "
Manner of Death K Natural Cause Accident El Homicide Suicide ❑Undetermined n Pending
„ Circumstances Investigation
Medical Certifier Name Title
Address q re,0 p 0 Q Q.( S CJ o ) ,,..4
12,76 Li
'rr Death Certificate Filed � District Numb r Register Numb r
} City, Town or Village ( ,\€.VAS Fag S , Iv� '' 5 o 0) l
❑Burial Date C etery or Cremat ry
❑Entombment I b )SD ) 07_3 V hu VI ,e,t3 Col JY\ L
Address
Cremation Z �J 0.r\ � � q. 2 S �fJ u y�L/ ()�
Date Place Removed
Z(❑Removal and/or Held
and/or Address
H Hold
tiY
O Date Point of
N.1 I Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
r;: Permit Issued to (� n CV S i CI _1 FC� Registration tuber
:fj Name of Funeral Home � � (,7�17� 1(44
Address S3 00 U cUr- n
iei - %uu2_tyts 60/y, Ai(' ( 2- .YeLl
•f: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:r; Permission is he eby granted to dispose of the human remains described above as indicated.
Y Date Issued 2.0n Registrar of Vital Statistics ll
•
;c (signature)
: District Number .560
) Place C�)en b
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ut Date of Disposition (0 13d 113 Place of Disposition 41-4-41j.t.,i (4*170 i?..T ._
2' (address)
N
e (section) 74/
(lot number) (grave number)
Name of Sexton or Person in Charge of Premises r• `. ....c � }
W (4p se print)
Signature /'" Title (Plem Wes✓
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 01761.6
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#