Bascombe, Maida NEW1ORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics - Vital Records Section
Name First Middle Last i Sex
Maa.da ..:. Base�e o nbe.......:...::.. Feria le
iffiii Date of Death Age If Veteran of U.S.Armed Forces,
March 6, ...1,98'�..... • 87...... War or Dates.,.. iro,
Z Place of Death Hospital, Institution or
lW City,Town or Village 0ranville, N. T. Street Address Erlrta Laing Stevens Hospital
:. ... . .....:............
1 Cause of Death
congestive Heari.- Failure
Medical Certifier Name Title
tl�
j.o)an....'-4.,.....x i enn.o
Address
::<>::. r.a. zi:l e., �Ze�AI .YTork.,....:.
....... .....:...:......
Death Certificate Filed District Number Register Number
City,Town or Village r.ra -.1.vi lie , N.Y. 5756 10
Date Cemetery or Crematory
• El Burial Ra.r. rra. . �..
. ..........?, :G 1.7.,:.�.. . 3.8 ..:: ...:.
El Cremation Address
.........glens Fall , zYork
Z' Date Place s RemovedI1-e =...
O', 0 Removal and/or Held
H and/or Hold .:,........:...
Address
>t/Y
a. Date...... Point of..
) ❑
Transportation
by Shipment
CommonCarrier .............................................................................................................
Destination
❑ Disinterment
Date CemeteryAddress
El Reinterment
Date Cemetery Address ......:....................::..:.:..:....:.............................
Permit Issued to Registration Number
Name of Funeral Firm Roe t 1 r. r F
Address
'1-ranvi1le Nov! work
:
, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
t Address
W:
Ai
Permission is hereby granted to dispose of the de un�man ren�yatip scribed above as Indicated.
Iiiiiii Date Issued Mar eh 6, 19 erhegistrar of Vital Statisti ►��1 J �'-
iiiiiiii (signature)
Oilli
District Number 5756 Place 3rgriv i lle, He,,.:: York
f
I certify that the remains of the decedent identified above er , is osetof ' c danoe with this permit on:
WI Date of Disposition .f (ic~.p j/�� Place of Dispositi6 / ��r"rv;
2 (address)
w
(section) (lot number) (grave number)
pName of Sector Person in Charge of Premises .� I c' 0 —✓ I e' 5" 5 j I
�` 7 a se print)
W• Signature �-- - ��- (--,! 1. ti,1,,7 - Title &r-s�-"°:, ., C4/9-r
DOH-1555(9/86)p 1 of 2(formerly VS-61)