Dillabough, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH tit
r Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn Dillabough Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/29/2012 84 War or Dates
�-. Place of Death Hospital, Institution or
w City, Town or Village NORTH CREEK Street Address Adirondack Tri County Health Care Center
iti Manner of Death X❑ Natural Cause 0 Accident Ei Homicide 0 Suicide ElUndetermined El Pending
0-- Circumstances Investigation
W Medical Certifier Name/ . p Title ,p
13
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t7cX1 (9c.3/ ei ,x�/ �/2J,c-,,--f(� �)-irDeath Certificate Filed rict Number RegisterIlym ber
City, Town or Village s5-6 CS—
c9 a
❑Burial Date 2 -Cemetery or Crem to
❑Entombment W/�Z /f/ L4 ' l(/ /mot,C.�f/lJL
Address
®Cremation Q(/ u g � //�� /)-�p
Date Place Removed
• Removal and/or Held
o and/or Address
H Hold
N Date Point of
E 1 El Transportation Shipment
CO by Common Destination
Ct 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
• Address
:
W
11, Permission is hereby granted to dispose of the human rem ins describ ab as indicated.
Date Issued g 2.Vl/A Registrar of Vital Statisticsc • � -
(signature)
District Number 5 6 j�" Place Q c is ^,_
U
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition q/4 It Place of Disposition ',„c,Um.► L 4)(w.
2 (address)
W
f/?
Ir (section) (lot number) (grave number)
p Name of Sexton or Person in Char a of Premises
Att'ct`��� ��''��
(please print)
UI Signature Title cxempraa
(over)
DOH-1555 (02/2004)