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Gardner, Constance
1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Sex V,:- Name First Mi 1 Last F�s�ez��AV Name Lo,oST C.,r-C / /h2►t�' L N is Date of Death I l Age If Veteran of U.S. Armed Forces, /2, // 0 12 S War or Dates AJ KJ' Place of ath Hospital, Institution or City, own' r Village C u .e`�.,IS Q : Street Address d3 3 l T Z L i/_ Manner of Death tv.. atural Cause ❑Acci ent ❑Homicide ID Suicide ri Undetermined El Pending Circumstances Investigation Medical Certifier Name Title t^ ii Address Z . -a1c) 3 I � �' y t2`' District Number / aegis r Number II:; : Death Certificate Filed City, Tow) Village , U L s z u 1 --, S(-61 1 l Date q b Cemeterylr Cmatory . I Burial ! ZLf (p [ /`I n)er ( / &A-0 > Address Cremation t7 /.6 v — S /3 -Ar Date Place Re oved Removal and/or Held •.• and/or Address Hold 0 ( Date Point of cani 0 Transportation i j Shipment fl by Common Destination Carrier Disinterment Date Cemetery Address - Reinterment Date j Cemetery Address Permit Issued to I Registration Number r Name of Funeral Home &Qke� �c er �cZ ��ome i Of 1 30 Address 1/ Lc ra €.tfc (5.1„. , o(,(.Q_ilsbu rc , Aim) 4Ufit /ca'6701 It Name of Funeral Firm Making Disposition or to Whom yJ Remains are Shipped, If Other than Above ! Address k ) `.: Permission is hereby granted to dispose of the human ern nu e{a as indicated. : y'<; Date Issued_ � i Registrarof Vital Statistics( D -`� ''" Zature) ~'# District Number Ste�� Place ©I,t'►t ¢A.r.c, I certify that the remains of the decedent identified ab were disposed of in -- •rdan•- with this permit on: f".-. EDate of Disposition 9/26/1 6 Place of Disposition ine View Cz, etery, !. eensbury, NY 2 (address) IA Hudson 3 51 3 tri (section) (lot number) (grave number) wName of Sext or Person in Charge of Premises Connie L. Goedert Z (please print) Signature G►- Del 46r. Title Cemetery Superintendent (over) DOH-1555 (9/98)