Madden, Gerda NEW YORK STATE DEPARTMENT OF HEALTH # (Cq
Vital Records Section Burial - Transit Permit
0 Name First r Middle Last S
EtZ`� iA i''�A tZ`1 �``�kZDEN
Date of Death
Age If Veteran of U.S.Armed Forces,
da 90 ks
1 I� �� war or Dates
. Place Bath Hospital, Institution or
City, Town r Village Mb P—E A v Street Address 1-�p M� 6 i Goo SN L p
Manner of Death®Natural Cause ['Accident Homicide Suicide Undetermined Pending
.41 Circumstances Investigation
Medical CertifierAP Name Title
( \ c3 A . �Ms-Lv )bc M"D
Or Address
Death Certificate Filed District Number Register Number
f City,Town or Village
Date emetery or Cremato
:: ❑-Burial Ooi /I 1aols t, N€ Qke`.) Lv_eMca�ti
Address w /'y
Cremation i')v p�e:Q. `cJ�� at,„ „, ►,gL1 z, ,\_, tag 04
Date Place Removed
0❑Removal and/or Held
t= and/or Address -- ---
al Hold
9 Date Point of
61 Q Transportation I Shipment
Ei by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to t Registration Number
Name of Funeral Home t� nand b. &LA& Fu-,,ecai Horne. Q()3O
4wv
< Address41 11 Laf
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
F Address
p
it
Permission is h y granted to dispose of the human r ascribed ove as indicated.
W.LI /Date Issued /� / Registrar of Vital Statistics_
(signature)
District Number45 - Place c (Y IIQ(f AV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-45 Date of Disposition Z l'1�M f 1 Place of Disposition 6-.«c t _
(address)
UI
CA
C (section) /(lot numbed (grave number)
0 Name of Sexton or Person in Charge of Premises +
g (please print)
Signature Title 014411M/Pz-
(over)
DOH-1555 (9/98)