Needham, Cynthia NEW YORK STATE DEPARTMENT OF HEALTH t *0-, 43 1
Vital RIicords Section Burial - Transit Permit
,
.„4.-g Name Okirst Middle Last Sex
Cynthia Needham Female
Date of Death Age If Veteran of U.S. Armed Forces,
' 07/30/2016 76 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Chestertown Street Address Deceased's Residence
Manner of Death 0 Natural Cause 0Accident Homicide � Suicide Undetermined n Pending
Pr! Circumstances Investigation
Medical Certifier Name Title
,;. ROBERT L. EVANS, ////,2 ; Address
g ONE IRONGATE CENTER GLENS FALLS, NY 12801
Dea ificate Filed District Number �- Register Number
at
Cit Town r Village C,7 off ( 5{o SQ G
a `0 Burial I Date e e or Crematory O
eV 08/01/2016 fi vl, , i �%%�� /d`ev..—z-i
ei❑Entombment Address �l, G
®Cremation
,,,
`, Place Removed
Removal Date
s❑and/or and/or Held
and/ Address
' Hold
Date
Point of
4 ❑Transportation Shipment
by Common Destination
;; Carrier
Disinterment Date I Cemetery Address 0, 0
s:
Reinterment Date Cemetery Address
rv. Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
itilti Address
•' 9 Pine St/P.O. Box 455 Chestertown NY 12817
K. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a
x Permission is hereby granted to dispose of the human remai 'bed above as indicated.
Date Issued E— —, c( ,Registrar of Vital Statistics QM,(,�,
(signature)
District Number 5 5 2 Place ‘-t.,c , CA/1 e- -- -e-i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition '1L��L Place of Disposition 12.0„ 6),,,,,,.....
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge Premises Itase print)
Signature Title CGa''Ot
(o'`
`''`'OOH--1555(02/2004)