Marra, Ethel ,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mid t le a Sex
L /
T-H� ea tz a- F,'/7ea.tr
Date of Death/ / Age If Veteran of U.S. Armed For As.
�-/S-//(, RI War or Dates Av
Place of Deat 1 Hospital, Institution or
City, Town Villa pv 5-,(f L ,,,s i3Zc,S Street Addr J el Z et iewo `1 r"2 G�,_)---
:.: Manner of DeatI Natural Cause 0 Accident El Homicide 0 Suicide El Undetermined ri Pending
Circumstances Ll Investigation
iiii Medical Certifier Name Title Ab
Address,
iiiil c__L de),) C eni- Q -6--Adl g /-19-a__s,
sii Death Certifi ed n District Number Register Number
t City, Town Villa e �JS7d �.(Gefrs
Date emete r Crema o
El Burial /F // /A)e-Crematory
Address
:': El Cremation U ftgv__ l� ^ / O r C. Uvi.,c/ /JL/
Date Place Removed '. fl❑Removal and/or Held
and/or Address
Eg Hold
Date Point of
CaQ Transportation Shipment
p, by Common Destination
Carrier
Disinterment Date Cemetery Address
[�• Reinterment• Date Cemetery Address
i Permit Issued to � 11 Registration Number
giii
i Name of Funeral Home 'rit ,at,Yt l ly6,-Y OI)39
Address �.,..
iiM
„,1 Ii 44 ,15- c; 0o asi¢u r 12x-O y
Ls Name of Funeral Fi Making Disposition or to Whom '
'k' Remains are Shipped, If Other than Above
Address
>;>: Permission is hereby granted to dispose of the human rem s described �ove as indicated.
>< I,/
' Date Issued 81�1 J kp Registrar of Vital Statistics A � •
(signature)
> 4` District Number /5 Place / S Cj k 2s Yz t17S
I certify that the remains of the decedent identified(above were disposed of in accordance with this permit on:
Date of Disposition 8/1 0/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W Horicon 30A 1
CC (section) (lot number) (grave number)
QName of Se or Person in Charge of Premises Connie. L. Goedert
g i (please print)
f . Signatur ' kith d�. Title Cemetery Superintendent
(over)
DOH-1555 (9/98)