Pelkey, Helen J ;
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First41_j Middle L ty,,,,
- S ...: .:..... O KEG:
Da f Death //�� Age If Veteran of U.S. Armed forces,
�l q .:::. 0 :. War or Dates
ZPlace of Death Hospital, Institution or
Bt City,Town or Village ij,t Street Address
r ii,t" s
G Manner of Death" Natural Cause Accident Homicide Suicide Undetermined ending
LtJ ❑ Circumstances Investigation
CMedical Certrfier:::. Name i ei . 'UM/V` Title.
Add res
Death Certificate Filed District Number. Register Number
City,Town or Village . �%�('� 4 ,..5601 7�
Date Cem tery or Crematory
j Burial
Addr s
El Cremation ,M.V • (OVb
Z Date ( Place Removed
O ElRemoval and/or Held
I- and/or Hold
Address
0:.:::,, .. . .:::. :,.....
a Date Point of
N' 0 Transportation by Shipment
a Common Carrier
Destination
El Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to / M Registration Number
Name of Funeral Firm `✓LI ?r '✓l(�'pctw _ ^i j� T J4i D iaO
Address to/ ecuuk- )k-i-red , jitoilm 4ct-bo 19),/ ' )
Name of Funeral Firm Making Disposition or to Whom f...........
2 Remains are Shipped, If Other than Above
::.::.Address
CC....
Permission is ereby granted to dispose of the hu rem ' s esc 'bed above as indicated.
Date Issued r)c Registrar of Vital Statistics '14)r9
(signature)
District Number rJ1i01 Place 0of )d u.° IrAJAJ
I certify that the remains of the decedent identifi above were disposed of in accordance with this permit on:
t- Corner Pine St. & Luzern Rd.
W Date of Disposition 5/1 /93 Place of Disposition St. Alphonsus Cemetery, Queensbury, NY 12804
E (address)
w Special Section "D" 87 1
= (section) (lot number) (grave number)
pName of Sexton or Person in Char of Premises Rev. Robert Powhida
Z (please print)
w Signatures,, Title Pastor
DOH-1555 (10/89) p. 1 of 2 VS-61