Getchell, Jean E 1
NEW YORK STATE DEPARTMENT OF HEALTH 3a
Vital Records Section Burial - Transit Permit
NaDae First Middle Last Sex
�q e_a..r T- C4e_-I-c ht,I 1 Rola k
Date of Death Age If Veteran of U.S. Armed Forces,
— 13" Z-0 l J 5 G( War or Dates t\J c
I` Place QLPIteath i� � Hospital, Institutio or
W City(FovLn)or Village L�i�-� LV,`;_..Q,.(l'',Q Street Address l C,V1 CX,L+' r
in .C7 ❑ Elm}Manner of Death1 Natural Cause Accident ❑Homicide Suicide C Undeterned E Pending
Circumstances Investigation
W Medical Certifier Na M Title
Aoildress f\ )
�I
Death Certificate Filed �uZ-E..t-� Di�rjc �er Register umber
City,(Tow or Village
ill❑Burial Date ':fir etery or crematory
s.„ Entombment Addr/�" � j
,,Cremation C-21UP-CA -6[J Li.IAA
Date NP Removed
2 r—I❑Removal and/or Held
0 and/or Address
~ Hold
LO
O Date Point of
0 Transportation Shipment
G by Common Destination
il Carrier
41
4 ❑Disinterment Date Cemetery Address
3❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home �i`e l,t -( -1--u,V\ t' 1 I I DyyLt 1 h C 0 Oa I I
Address
01- Ckw( cif, Stt-- L c&i Lea zc_,(-- f\N
15 Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
I
W
aPermission is hereby granted to dispose of the humans ains des ri a above as indicated.
Date Issued ) )3-2.0 l5 Registrar of Vital Statisti r //?A45.-
(signature)
District Number rpS ito Placeo , c t La. k Last- 7ri.----
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition il�y/fs Place of Disposition 'I ant. t1.. errvrtetcrii...-
(address)
W
Cl)
rt (section) /j (lot number) (grave number)
4
p Name of Sexton or Person ' Charge of Premises r=S � ,S -
Z ( lease print)
,.- Signature Title aMdl .
(over)
DOH-1555 (02/2004)