Thordsen, Helen Si ."Vit 41 N
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
/7e...ie, '/h 01Q-- ,S�v) 'z'v /
Date of Death Age If Veteran of U.S. Armed Force',
2 -to - c;, /i kl War or Dates
- P -ce of Death Hospital, Institution or I� !.�—
al Town or Village a Troy Street Address 5'�,,,,�.. cis tr,� , / _
0. 1 anner of Death Natural Cause 0 Accident 0 Homicide Suicide Undetermined 0 Pending
IliCircumstances Investigation
W Medical Certifier Name Title
o s IZi Qq:� /40,,,;,.., M)7
Address y% c�
,-,2 / V w�i� � /(.o�{ i iv /).-7 l2
-.th Certificate Filed District Number ) Register Number
in Town or Village of Troy 4102
■Burial Date / 1 Cemetery or Crematory
Entombment �'� ' / tr _ /' 174(��� (/c > �.�v -ems e
Address col El�Cremation �) g -e- ,2 RoJ `` /�t �°G�.i "`
Date Place Remove 7
❑Removal and/or Held
and/or Address
*" Hold
0Date Point of
Q Transportation Shipment
5 by Common Destination
Carrier
> 'Q Disinterment Date Cemetery Address
'`<:Q Reinterment Date Cemetery Address
Permit Issued to e istration Number
Name of Funeral Home Crti / , c;,,, (4 2.Z/ . ,�1�1�7 i O1�11.
Address 2
li /L' 7 '0C.G— It�� ' [i tv��cSbi. Lzr- / '1'c l /�` bC12'7
Name of Funeral Firm Making Disposition or to om i
14 Remains are Shipped, If Other than Above
2 Address
It
ll
(` Permission is hereby granted to dispose of the human remains described above as indicated.
Sub-Date Issued ,� I a))' Registrar of Vital Statistics S4 . cr 'f.'J/1-t'`)S'-1
(signature)
<; District Number 4102 Place Troy Police Department, Troy, New York 1a 18a
. <; I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
III Date of Disposition Feel qq IZt+11 Place of Disposition . 'P,�t Utrw Cisw ..
14t ,.
2 (address)
W.
i/
CC (section) /� a (lot num _) (grave number)
0 Name of Sexton or son in Charge f Premises C '''r�%toON r -e nrr(l-
2 1 (please print)
i Signature /74 Title MC; M r}i OE,
(over)
DOH-1555 (02/2004)