Tremblay, Barbara NEW YORK STATE DEPARTMENT OF HEALTH. ,. , 23-9 g
Vital Records Section
Burial - Transitermit
Name First r Middle Last la\ Sex
<' `lD
Fite
Date of Death Age If Veteran of U.S.Armed Forces.
P q 1 Z-2 1 \4 ' '`l War or Dates N i .q-
.. .:'tio, Place • l-ath Hospital. Institution or _ J
13 City • ,/ Wage CQQ319uv Street Address 3 07 A-v ► 0
CXJILr
Manner of Death KNatural Cause El Ant 0 Homicide Ei Suicide n Undetermined n Pending
Circumstances Investigation
i Medical Certifier Name �� E Title
' , Address
: V)ree. 1 Cc C Cil na.eY C ue6 Falls,_ id q 1 )
'f` Death Certificate Filed t Nm�er Regis umber
3 City. r Wage I,JI�ySLY1S\0U r' ) j
Date .-,2 1 •
Cemetery or Crematory
❑Burial q 123 I �14 ..i n e V e UJ eremako(-1
)
Cremation VlSbU('`� ) � jDate �/ Plac Removed
it❑Removal and/or Held
E and/or Address
a Hold
Date Point of
t__.t Transportation Shipment
• by Common Destination
Carrier
❑Disinterment Cemetery Address
.:- Li Reinterment; Date" Cemetery Address
j g Permit Issued to �j )) Rep iration Number
al Name of Funeral Home /IRy.c),1tLi1 )). -Riir ,F'"i.;,.,c�,'t.ri-t./� H6- 0)13C
^}: Address /
il
J Name of Funeral Fjtrn Making Disposition or to Whom Ay, -
Remains are Shipped. If Other than Above
Address
1
r
�:: Permission is hereby granted to dispose of the human remains described above as indicated.
1
' : Date Issued} ? j tLi Registrar of Vital Statistics C_--,_ el 6 L� 11..:i__..,_
a {s mat
iii District Num tg c ) Place ( 0 Li-.,--, �.-'L
•
I certify that the remains of the decedent identified above were disposed of in a dance this permit on:
Fki Date of Disposition 1111,014 Place of Disposition ,'Irw/"— � r
{address) .
tt!
C (section) A (lot ber) (grave number)
0Name of Sexton or Person in Charge of Premises G n{'4�r + 1
z (please print)
t . Signature �/�. ,s----- Title CpAtisiiVe
(over)
DOH-1555 (9/98)