Flewelling, Barbara NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section
Burial - Transit Permit
'' Middle Last ( Sex
?r. Name First i�
&--OoarC� o lax .e\e\O e\l;nq
Date of Death Age If Veteran of U.S. Armed Forces, J
p\ o\ I ZO\ 8a War or Dates N IA
....,tt Place of Death Hospital, Institution or
i.tCity, own r Village (L,,QQ v'C-`
�S\O \ Street Address i kS r nec4-i c v\- 4 e.. .
'� Manner of Death wit Natural Cause Accident Homicide 0 Suicide Undetermined n Pending
ate t�V Circumstances investigation
iliMedical Certifier Name (�O,^ r� e Titlefyi 0
Ci Y3e
!,.; Address
t> 3 1 r_onva.4. Gov- _1AirlS \` 1 12- <()J
2.< Death Certificate Filed i District Number Register Number
Si City, ow. a Village pj 11�Q.()c\130r I s �� —2 f
�t Date I Cemetery or Crematory
>::1�Burial OI I O$ 1 201. ..Q ( c Yne \► \0 ce'1-2.2'\C
Address
:. ❑Cremation _ ns\-31 ,r. t 01 1 8b41
Date i Place Removed
g❑Removal l and/or Heidi
•- and/or Address ---
Hold
9 I Date T Puint of
N0 Transportation _ _ j Shipment
G1 by Common Destination
Carrier
Date Cemetery Address
0 Disinterment {
Reinterment Date I Cemetery Address
!.: Permit Issued to Registration Number
Name of Funeral Home &titer Fwiecc-1 name. of . �o
<< Address
01:1 /lLa�ate 'OJ 3t. , bku ns urcj ; Ne to % T _ /
Name of Funeral Firm Making Disposition or to Whom
T'" Remains are Shipped, If Other than Above
44 Address
114
a
:.; Permission is hereby granted to dispose of the human rem d i• - • • •ov= • dica ed.
Date Issued i— 14-a D l(f) Registrar of Vital Statistics T) A 1
i (s. ture)
_'<s District Number `5 .61 Place WI,, AI certify that the remains of the decedent identified abov re disposed of in ordance ith this permit on:
1,,,,E Date of Disposition 1 /8/1 6 Place of Disposition ne View Ceme ry, ueensbury, NY 1 2804
2 (address)
ILI
1E Huron 1
cci (section) (lot number) (grave number)
flName of Sex n or Person in Charge of Premises Connie L. Goedert
z / (please print)
tal Signature, /Leis e -R-cti2-,r Title Cemetery Superintendent
(over)
DOH-1555 (9/98)