Archambault, Louise NEW'YOR1 'STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First • Middle Las Sex
4_0(tise S, Arc hambau(f-
Date of Death / is Jo j Age If Veteran of U.S. Armed Forces,
i I 9 War or Dates
F- lace of Death c ' S r0.(IS ,Hospita, s ut+era-er /'/ens falls �; 1Q.f
W City ge f 1 &poet Address C7
;p Manner of Death 'Natural Cause 0 Accident El Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name itle Imo
CI Name t\1
Address ('�
eroa_ sio,,\\ AC±L_
crtificand ��/e n S Fct/�S District Num + Regis • ,er
Cit j46
urial Date J LA_, i Cemeter {�
❑Entombment - �__-- T n e V `i e v..)
[Cremation Address Q Ltak r n c i QLL ' laulc
Date i Place Removed
Z Removal I and/or Held _
2❑and/or - - _ - - --
I Address
Hold -
-
O . Date I Point of
a.tf) Q Transportation _- T� Shipment
O by Common Destination
Carrier
Disinterment Date ! Cemetery Address
Reinterment I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home fi`'r 0\1 naf ci I. i Ler ri----LLner a.t o r-v- ! Q L 1 30 •
Address
1\ a-Ccky c H Q `s.. , C k_a.C n=:bu,(,/ , ti e v... y u r L 12 (2)`---1
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
CI` Permission is hereby ranted to dispose of the human r ains described abov as indicat
Date Issued 6 Registrar of Vital Statistics
(signature
District Number �' Place /ce_ e.<7,,-- w
I certify that the remains of the decedent identified above were disposed of in accordance with is permit on:
UI Date of Disposition 7/20/2011Place of Disposition Pine View Cemetery
2 (address)
ILI
W Unadilla Ext . 39B 2
it (section) [lot number) (grave number)
gName of Sexton or Perso n Charge of Premises Michael Genier
(please print)
Iii
Signature ' ,+?ivww __. Title _ Superintendent
(over)
DOH-1555 (02/2004)