Keough-Bruce, Ursula L t-7^1
NEW YORK STATE DEPARTMENT OF HE;LTH;
Vital Records Section Burial - Transit Permit
;:ti Name First Middle Last Sex
if, Ursula Ann Keough-Bruce Female
n Date of Death Age If Veteran of U.S. Armed Forces,
06/09/2016 49 War or Dates
•f Death Hospital, Institution or
raflirep7own or Villase Glens Falls Street Address Glens Falls Hos.ital
rIki?41 -nner of Death Natural Cause 0 Accident 0 Homicide El Suicide Undetermined El Pending
Circumstances Investigation
rill
Medical Certifier Name Title
Noelle Stevens,
Address
Broa Street Glens Falls NY 12801
D-- Certificate Filed �' District Number ( ter, Regist er
Z r i 0.own or Village e .ram � �VV
V❑Burial Date Cemetery.or Crematory �-' �----
06/13/2016 ,i>7.. L- -—'�c� ALP. d ivv'/
ok Li Entombment Address ` �
ti ®Cremation (( i _.P— ,A✓r 7 7
� Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
oTransportation Shipment
'-fli by Common Destination
Carrier
. Disinterment Date Cemetery Address
Zri,i LiReinterment Date Cemetery Address
t Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
i is Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
o Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
7 4 Permission is hereby granted to dispose of the human remains described above as indicated.
,44 Date Issued a / i 3 //% Registrar of Vital Statistics (A)
,k (signature)
District Number s 60 l Place 6 S VcA \\ S N y /2p I
od
hfa I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition io Zit,//t( ik Place of Disposition O-_- C/7
r .W*''-''
(address)
,. (section) /(1ot number) (grave number)
`l Name of Sexton or Person in Charge Premises t�^''") S -
(prase pant)
Signature a Title Cflehitn
(over)
DOH-1555(02/2004)