McDowell, Ruth NEW YORK STATE DEPARTMENT OF HEALTH _ , IlL
it 33
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth McDowell Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/29/2011 100 War or Dates
I"' Pla - •_!-ath Z 21 n� s'a.,-- Hospital, Institution or
W Cit Tow- or Village Id'6R REEK • Street Address Adirondack Tri County Health Care Center
Manner of Death IJ Natural Cause Accident 0 Homicide Ej Suicide ri Undetermined El Pending
„) Circumstances Investigation
-7A 2W0 Medical Certifier Name 1 Title
; * ,64 / AZ/ l/ er_,,,,,4 y _ .)_,ps--_,
Death Certificate Filed District Number Register Number
Cit Tow Ar Village C2/ t/ 5-.6 .S 7_9
❑Burial Date or Crematory
Entombment 06/30/2011 Jy2e £ -e ( '2-e L ,/C/fl c>ri�j
Address �
®Cremation C CJ`CC a-7 ,W ai,4 _e_. 2.nu,c,,-. .(. ,-2,tpe, v
Date Place Removed
z 0 Removal and/or Held
0 and/or Address
F Hold
N Date Point of
ci. El Transportation Shipment
0) by Common Destination
El- Carrier
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00134
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
w
II. Permission is he eby granted to dispose of the human remains described a e as indicated.
Date Issued 0 o(-7I �i Registrar of Vital Statistics A lcA-cam
(signature)
District Number �6 J-Y Place I trji U 0 11 nS 1-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 4.-30-it Place of Disposition Pm C+w...c{-orti.-
W (address)
CO
r (section) (lot nu ) (grave number)
0
p" Name of Sexton or P on in Char of Premises r1s @'^'�r
Z { (please print)
W Signature Title OM rM dp
(over)
DOH-1555(02/2004)