Christ, Doris NEW YORK STATE DEPARTMENT OF HEJ LTH\t 1'/6
Vital Records Section Burial - Transit Permit
', d Name First Middle Last I Sex
AZ
Doris K. Christ Female
Date of Death Age If Veteran of U.S. Armed Forces,
a 12/14/2016 �� War or Dates
a Plac o e th Hospital, Institution or/ ����, j `1, l/y� .
- ' City Town r Village @1 psi:eelvitlEr, 7/1.(�f(� Street Address Deceas Residence
. Ma of DeathsUndetermined Pending
Natural Cause Accident Homicide Suicide
Circumstances Investigation
Medical Certifier Name //�� . Title
Elizabeth Maher,
Address
r 24 Fairfield Ave Schroon Lake, NY 12870
Death = irate Filed " p/ �y District �3ber I Register Nu �,ere
City, o . or Village � //'lam /�Tl G 'J I i
' ❑Burial Date Ccii16tery or Cr matory �,
❑Entombment 12/14/2016 O/J� -e. � � 4•/ /lei
Address
,�®Cremation 6?L,[%e,044cries7 /.)--r ‘1
AN1 Date P)a& Removed
^❑ Removal
and/or and/or Held
Hold Address
Date Point of
Transportation Shipment
by Common Destination
tt Carrier
a ❑ Date Cemetery Address
$.1 Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
- 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
Address
1,4 Permission is hereby granted to dispose of the human ains described above as indicated.
Date Issued (a--t 04 Ia.o IL,Registrar of Vital Statistics ___ �- ,c;) -l--__-,
(signature)
District Number 15 5 ( Place "j ci , -,,-� e y u-a
-64
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ii Date of Disposition 12/IV/0Place of Disposition ?,h 2. U re Go Cie 4 4..IO/-
(address)
rd
(section) (lot nu ber) (grave number)
,, .,-„
Name of r in Charge of Premises vvl-/, ✓1 UG m 4 64e
�� Sexto
r (please print)
�, G ce M& ./
Signature Title -
(over)
DOH-1555(02/2004)