Haydel, Stella NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
in Name First �I Mk dle - Last Sex r Te.. t I A. ,, I
Date of Death /Si
- ��� Age If Veteran of U.S. Armed Forces,
/'
War or Dates
Place of Death Hospital, Institution or,/
Gity;-Town or Village V PGh S L✓"- Street Address .�S T iat"-at"-,MManner of Death Q Natural Cause 0 Acident 0 Homicide 0 Suicide ri Undetermined 0 Pending
Circumstances Investigation
Aim Medical Certifier Name 0 V
I •TitleM
1 -Cry `' d 1 4j VI '0w
Address
piii fa Su a//4 SF refs Ci& iv5
iiiiiiiii Death Certificate Filed District Number Register Number
iiii City, Town or Village (pc') ID, -
Date // /�j/ Cemetery or rema ry
.. r...„
-burial ! 1 '! / "`l. d o/S- 4 ''i.� CC-4/ I
Address 1
❑Cremation •
Date Place Removed
O❑Removal and/or Held
.- and/or Address
Hold
Q Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Hi:iDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Regist atipQ J r
`:'<• Name of Funeral Home SULLIVAN,MINAHAN&POT ER 0 1� cifer
Address 61 PARK STREET
iiiiiiiii GLENS FALLS NY 12801-4454
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
*' Address
s
A.
Permission is hereby granted to dispose of the huma r ains desc ' d a ove as indicated.
Date Issued 1 I._�-_G�'(p Registrar of Vital Statisti s 0---)Ds ature)
iiiiiii District Number C,1 Place
I certify that the remains of the decedent identified abov w re disposed of in acc an e with this permit on:
.1 . Corner Luzerne Rd. & Pine
ill Date of Disposition 11/5/96 Place of Disposition Queensbu NY 12804 St.
(address)
Li! Special "D" 35 1
N
CC (section) (lot number) (grave number)
GName of Sexton or Person in arge of Premises Rev. Robert W. Powhida
g g ��,, (please print)
44 Si natur \-- I Title Pastor
DOH-1555 (10/89) p. 1 of 2 VS-61