Polihrom, Angelina lt
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
`< Name First Middle Est Sex
Date of Death Jiiii
Ai g Age If Veteran of U.S. Armed qorces.
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- - e of Death (�'' / Hospital, Institution or
,b 3' own or Village L L9'7.US I'gvt, S Street Address 2 7 —7- 6J ert r2.tr,,.) ci�.
anner of DeatiVr Natural Cause Accident Homicide �Suicide Undetermined Pending
l�, Circumstances Investigation
Medical CertifierILI Name /� Title
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•_- t Certificate Filed District Number ' R aster Nan
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Date / l mete r Crem ry
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Address
: ❑Cremation
Date Place Removed
❑Removal and/or Held
r_Leand/or Address
Hold
Date Point of
eiQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
i: ElReinterment Date Cemetery Address
1 Permit Issued to � // Registration Number
M. Name of Funeral Home n ,ii ,N , RArt�2 / �:,�,i�' C_AI,,,— 0119 v
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<' Name of Funeral Fi Making Disposition or to Whom r�
Remains are Shipped. If Other than Above vUU`/
Address
1
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iiiiiill Permission is hereby granted to dispose of the human remains de bed boys i i d.
II Date Issued 5130 1 a 6 Registrar of Vital Statistics .--- )
(signature} -
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<` District Number ,�j �b ) Place /
<: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
5 Date of Disposition 5/31/06 Place of Disposition PINE VIFW CFMFTFRY,OUFFNSRI IRY NY
(address)
ILJ SENECA • 19-A 2
(section) (lot number) (grave number)
Name of Sexton or Person i Charge of Premises M I CHAEL 6EN I ER
z (please print)
W Signature _ Title SUPT.
(over)
DOH-1555 (9/98)
CAMERON
01;. () Lot No. 19-A
Address 44 Dean Rd. Hudson Falls NY 12839Section No.
Owner David & Mary Lou Cameron Plot Seneca
Date 11/4/02
Approx. 200 Superficial ft.
Location Bounded on North by Gavin, Winchell, Nooney & Vacant , South by
Vacant , East by Path, West by Path.
Corner Posts
Remarks 9I2_Lo Its no Thoa2_ ShruJ c pol
Deed No. (and changes) 3204
Payment Record Paid in Full 11/4/02 (&2 ,400. 00)
Record of Interments V`\
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32 ANGELINE POLIHROM 5/31/06 P �S P
4 `X, x
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'' I Jonathan M. Cameron 11/7/02
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11
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Form No. 01
)4AME POLIHROM, ANGELINA (LF)
Age: 63
Cause: NATURAL
Lot Owner: DAVID & MARY Lou CAMERON
Lot # 19-A SENECA
Grave # 2
Case # CONCRETE
Died: 5/26/06
Interred: 5/31/06
Undertaker:BAKER