Winchip, Beverly NEW YORK STATE DEPARTMENT OF HEALTH` # t;{(9
Vital Records Section Bursa! - Transit Permit
n Name First Middle Last Sex
Beverly Grace Winchip Female
�.A Date of Death Age If Veteran of U.S. Armed Forces,
07/01/2014 74 War or Dates
Place of Death Hospital, Institution or
City, Town or Village GLENS FALLS Street Address GLENS FALLS HOSPITAL
Manner of Death 0 Natural Cause 0 Accident Ei Homicide 0 Suicide El Undetermined ri Pending
,,,s,
Circumstances Investigation
Medical Certifier Name Title
.C u Z unn a Offilh
Addres 6- 7 Ifto i 4 i J " 4(Aeir_ef. ,c-t6ffith Certificate Filed 1' // District Number ster Number
, Town or Village f Ka` 57R.0/ .�• o
❑Burial Date C �r Crpto �c
07/02/2014 ert�►'/%Zp !/[ 9 C /d4,",',7
❑Entombment
Address
z®Cremation CR,t1-e-eyi4S 'Ui l 1 1)c V
Date lace Removed
4:0 Removal and/or Held
and/or Address
Hold
Date Point of
I'Is❑Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
ElReinterment j Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
' Address
1
,� 9 Pine St I P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
is herebygrant d to dispose of the human re ins de cribed ab a as indic.ted.
����; Permission P ,n,�P
1-1 Date Issued C3 /OZ/2oJRegistrar of Vital Statistics p� v G�
(signature)
District Number ` 60 1 Place ,� -f, 7 '=:7— c4 /7 C�
1
I certify that the remains of the decedent identified above were disposed of in accordan ff with this permit on:
Date of Disposition 1-3"N1( Place of Disposition C,r^^ Or''--
(address)
1 . (section) (tot number) (grave number)
'. Name of Sexton or Person •' Charge of P emises
(p1 ase pn
Signature 1--- Title (Kim-Mt
t
(over)
DOH-1555(02/2004)