Ramsey, Joan M
,_ NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
=;:1 Name First Middle Las)) 4 Sex
J 619,.E LI Z v7/ IC 91l c I d t/9L v�
''` Date of Death Age I If Veteran of U.S. Armed Forces
I
1 (e/I7 -7 e 11t_3or Dates „) {g
f 1e e of Death Hospita. nstitution or
City, own or Village �( ',i� 1�e u,s Street Address C r;�s �` c,S
anner of DeathNatural Cause [�Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name �e.a-(1 � h True P S I Clan
Address
btu Po-,-1,- Si , , U ,QAL3 Pa lm, (vim/ 12- p \
th Certificate Filed j� I District Number Register Numbet
City own or Village �j (A5 JS / t ,S 5 b 0 1 2
►:urial I Date / /r Cemete- -Crem oryEntombment / U ! /'`I /t�
Address I �
❑Gremation �j U6/L 06 .s_cr ` ,A7
Date I Place Removed �
ZC Removal I I and/or Held
and/or Address
le Hold
tea
Date Point of
C Transportation Shipment
Es by Common Destination
Carrier 1
` Disinterment Date Cemetery Address
'" Reinterment Date Cemetery Address
Permit Issued to . Registration Number
Name of Funeral Home L ,�L� i- V�it -c-c-k\ hp- L;j 1 0
Address
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
til
Permission is hereby granted to dispose of the human remains,descrriibed above as indicated.
i- Date Issued ( )C'1 I Z-(2 I l Registrar of Vital Statistics �CkA, ' '/ `
(signatur )
District Number 560 r Place 6 S Fx I S N V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lil Date of Disposition 1 /1 0/1 7 Place of Disposition Pine View Cemetery, Queensbury, NY
t (address)
DI Mohawk 64A 2
M. (section) (lot number) (grave number)
Name of Sextn or Person in Charge of Premi s Connie L. Goedert
z (please print)
Signature :L. O/(i1, z uG Q C ' Title Cemetery Superintendent
(over)
DOH-1 555 (02/2004)