Hayes, Tina NEW YORK STATE DEPARTMENT OF HEALTH # b I o
Vital Records Section
Burial - Transit Permit
Name First Middle Last Sex
Tina M. Hayes Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/21/2012 54 War or Dates
l Place ath �� e s7,�/- Hospital, Institution or cJ /6./� A 2
W. City, or Village plc Street Address Deceased's Residence
Manner of Death D Natural Cause El Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
,..,
W Medical Certifier Nam ; Title
A d 7/"s 3-- tag
Deati - ificate Filed ll �,, - District Number . J. Register umber
City,To or Village C/CC�S-�-ecl .,5
❑Burial Date Ce tery or�jrem to
11/23/2012 .✓'/t, l 4/ ( j/P kV/h/h1
❑Entombment Address //U
®Cremation Q�J� 6 f 'r` ✓v- j )--off c./
Date Place Removed
z El Removal and/cr Held
0 and/or Address
p Hold
a Date Point of
a0 Transportation Shipment
01) by Common Destination
a Carrier
Disinterment Date Cemetery Address
0 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
W
O. Permission is he by gr nted to dispose of the human re :in-desc be• at), . .s indi ated.
Date Issued /2_ Registrar of Vital Statistics / / F / • (-r', _
7 (signature),
District Number l . Place
� l 0 U 1 C her-j .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition tl l/1l11- Place of Disposition 'S(�s.Ouw C044r1_-
(address)
W
CO (section) (lot number) (grave number)
zQ Name of Sexton or P rson in Charge o Premises G�r'�} — ` y""`�i`
(please print)
W Signature Title f: mA-To l
(over)
DOH-1555(02/2004)