Forbes, Joyce NEW YORK STATE DEPARTMENT OF HEALTH ' - 1 # Z 11 "
Vital Records Section Burial - Transit Perrot
Name First Middle Last Sex
Joyce Ann Forbes Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2012 78 War or Dates
Place of Death Hospital, Institution or / r j
w City, Town or Village Chester Street Address , �,5/(/1411(s'107� ar/��
Manner of Deathinj Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
0 Circumstances Investigation
WW, Medical Certifier Name Title
PAUL BACHMAN, /'�/f.
Address
3767 Main ST.Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village S-�--G-7 ,5". 52 .. .3
❑Burial Date Gemetent o(Cremat ry
05/25/2012 /rl/'�K 'I/L- (''Al4r/U,-)v,-�
❑Entombment Address ) U �J
®Cremation (t)C,7 , R' c.�2P�I,.r—A.., _ '/...2_,FP`-/
Date Place Removed
z El Removal and/or Held
p and/or Address
E Hold
N Date Point of
pa„ 0 Transportation Shipment
N by Common Destination
CI Carrier
Disinterment Date Cemetery Address
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
I— Remains are Shipped, If Other than Above
2 Address
W
f1 Permission is hereby granted to dispose of the human r a •s desc a as i dicated.
t{Date Issued ,& ,2 /A Registrar of Vital Statistics ,�.
(signs um)
District Number&(o5a Place / ,h., �C, / 3/7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition �)21111 Place of Disposition •f?LOuv Choir`
2 (address)
W
a (section) 1 (lot number) (grave number)
p Name of Sexton or Person in Charge f Premises t41.,it-. c N> --
Z ij1 (pl se print)
W Signature (/ -- Title C Ki 0►2.
(over)
DOH-1555 (02/2004)