Semchuk, Mary PERMIT MUST ACCOMPANY REMAINS TO DESTINATION
FORM EST-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO
BURIAL TRANSIT PERMIT 2.CITY OR TOWN
3.DECEDENT'S NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
MARY PIZIURA SEMCHUK FEMALE NOVEMBER 3,2013
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
99 Years MAY 2,1914 WOLFEBORO CARROLL
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation 5.Mausoleum 6.Other): CODE: 1
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINE VIEW CEMETERY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) NOVEMBER 6,2013
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FINAL DISPOSITION(City/Town,State)
16.FUNERAL DIRECTOR BRIAN C LORD 17.N.H.LIC.NUM ONLY 699
18.NAME AND LOCATION OF FACILITY(City/Town,State) LORD FUNERAL HOME,WOLFEBORO,NH
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
BRIAN C LORD WOLFEBORO NOVEMBER 4,2013
413. " " m•3 1
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25,SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
. .f .`m ,t ,,f•11
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
(Month,Day,Year) (City/Town,State)
30.SECTION 31.GRAVE NO. 32.SIGNATURE OF SEXTON OR PERSON IN CHARGE
This permit,after being signed by the Sexton or person in charge(or by the Funeral Director where there is no Sexton)must be forwarded within six days to
the clerk of the town in which the disposition takes place.