LaPointe, Dolores C 1017
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First O�� Middle LLas� 0 k Sex
�c'� � Q U 1
Date of ath Age q If Veteran of U.S. Armed Forces,
11111111111 l 2 2v 202-3 Cd War or Dates
Place of eath Hospital, Institution or
ii City, Town or Village Sw!-ti+n 9 a Street Address S ci 19 f-Qgvt i-bSp,t�l
Manner of Death 1 Natural Cause ❑Accident ❑Homicide ❑Suicide El❑Undetermined El❑Pending
IliCircumstances Investigation
to Medical Certifier Name ) �� Title .� -b.0Ru -091n
a.Address N Y ,2 co
s Death Certificate Filed District Num e�� r U Register Number
^-^ 9
City, Town or Village ; l IPDS q56 i 7 2_2_
iiii El Burial Date12 z(.0/ Z Ce tery, _or C`r eatory
LO
DEntombment (Xm
Address I,� 1
';Cremation Q9imlo -ow() , 1 ),e,w Vol-tC
Date Place Removed
Removal and/or Held
and/or Address
i= Hold
O Date Point of
Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
!i Permit Issued to COYhr(6..q6/0,,k__
Registration Number
Name of Funeral Home �—(,t, t a_i CaiT CxY (---I
Address
L{o_z_ Ave 1 ` 7 riffs) ��l LQ Co
Name of Funeral Firm Makin Dis osition or to Whom
9 p
• Remains are Shipped, If Other than Above
• Address
a
Lti
Permission is her by ranted to dispose of the human remain de ed a ,a in ' ated.
Date Issued 2 Registrar of Vital Statistics 1R1.
(signatur
iiiM District Number 45 Place cLi 01-- wo►n�
t I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k>;,
ill Date of Disposition i}-�,(-;-3 Place of Disposition p)v,.c. V,Li,) Gctrw4 6?/
(address)
lAi
V)
CC (section) (lot number) (grave number)
Name of Sext n or Person in Charge of Premises T-cfriA/Y S&. 1 rvs"
2:. (please print)
Signatur 11 y�,. Title Greierd 0'
(over)
DOH-1555 (02/2004)
2
Public Health Law Sec. 4145(2b) L' "' v
Receipt
s
Human remains of delivered on , 20
.( , j /p
Fine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#