Godette, Alice NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sy
<> Date of Dea:th
Age
'> if Veteran of U.S.Armed F es,
/,;_,24,--1Q War or Dates
a
Z
f City,Town or Village w I1, Street Address J
Cause of Death 1
::W
;tl Medical Certifier N Title
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Q
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Address ,,,A6,-), e (......
:: Death Certificate piled'/ `� o ' District Nu o Register Number
<€ City,Town or Village `� ,/
Date { Cemet r Crem
urial 3
•
//
Cremation
Z; Date P ce Remov
O ❑ Removal and/or Held
and/or Hold Address :: ...�..................::::::..............................................................::::::...................::::::::::::::::::
Addres
Cl)
i Date Point of
Ni ❑Transportation by`:' Shipment
iita
Common Carrier
Destination
: Date::::::.....................................................
❑ Disinterment ii Cemetery Address
❑ Reinterment D e Cemetery Address
•
Permit Issued to Registration Number
Name of Funeral Firm mac. .4,- `,
Address
Name of Funeral Firm Making Disposition or to Whom
" ' Remains are Shipped, If Other than Above
.....................................PP........................................................................... ......................................................................................................................................: :.....:..
................................................................................................................................................................................................................................................. . . ............
Address
Permission is hereb granted to dispose of the human remain described above as indicated.
gR Date Issued Registrar of Vital Statistics -,L.A.
ignature) G.
ill District Number • 0 / Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 4/1 1 /8 9 place of Disposition St. Alphonsus Cemetery, Luzerne Rd., Queensbury, NY
Alt
(address)
w I Row R 10 7
(section) (lot number) (grave number)
p Rev. Joseph A. Falletta Name of Sexton or Person in Charge of Premises
Z -- (please print)
Signature - (t , Title Pastor
DOH-1555(9/86)p 1 of 2(formerly VS-61)