Norcross, Meri NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Tra ns it) Permit t
Name First Middle Last Sex
',4 Merl M. Norcross Male
5t . Date of Death Age If Veteran of U.S. Armed Forces,
01/07/2017 89 War or Dates World War II
Place of Death ,Z%�i rpy, Hospital, Institution or e/may 57 /jj,�
City, Town or Villaget a Street Address Deceased's Residence
Manner of Death a Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name p �� Title
Sarah Thompson,
Address
3767 Main Street Warrensburg, NY 12885
Deat =�•i icate Filed District Number Register Number
Ora City, To •rVillage 7�r/C 3-&54- I
❑Burial Date or Crematory
01/09/2017 j�� J/� /v5-/4/�,
_'0 Entombment Address � /
®Cremation �(/C -� �(/�/c/r , Z..2 y
vt
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
SP, Date Cemetery Address
M% 0 Disinterment
1
r-fi , Reinterment Date Cemetery Address
, Permit Issued to Registration Number
f Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
4447
IP Address
, 9 Pine St/P.O. Box 455 Chestertown NY 12817
!, r Name of Funeral Firm Making Disposition or to Whom
sr= Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described abo as in 'cated
,_` Date Issued -q. /7 Registrar of Vital Statistics � - �%
-
C-,Z (signature)
T" District Number 5 5 {-4 Place -1 ( )/- Gc)v'\--
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p Date of Disposition I//o f iJ Place of Disposition ent"ct„/ Cr n40fµ.
- (address)
(section) /� (lot number) it_ (grave number)
r Name of Sexton or Person in Charge of Premises G ^<' � t
( ease print)
Signature 0 �� Title CRPA)r` M-
(over)
DOH-1555 (02/2004)