Hoyt, Ethel NEW YORK STATE DEPARTMENT OF HEALTH , 411
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
6r�� MA4 //Orr 4
Date of Dleoth f Age / If Veteran of U.S. Armed Forces,
7QN 64 a'�I7 7b War or Dates PM
1- Place of Death ' Hospital, Institution or A1)K• I1edlul(, 'T F7.
-6ity, Town a ge ic/Ajl j'rJ Street Address . 4R AJJAL �A/Ce— , ivy/
ill
Manner of Deaths Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 f7? 4Nk. /VOG,J/FJ /9 .
Address
1/,3/4 1-44)' & egiljr'-, S'�'Z4 )A ai e NY izq ss 3
Death Certificate Filed District Ni4mber Register Number
Ctityr-Town-er Village SA/24VAC. t444& - /
DBurial ' Date-ram Cemetery or Crematory
T4
❑Entombment 4) 0), cgO/y ?WC' Mai) O q��y
Addees j 1 (��4/4 �D Qv,� t
Cremation �C, f�,J,f� S NY
Date Place Removed
Removal and/or Held
2❑and/or
Address�,,;
Hold
0 Date Point of
`i Transportation Shipment
0 by Common Destination
Carrier
3 0 Disinterment Date Cemetery Address
>j El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home/y. lg. (kiwi/4 f 1/1JL • o!O 7,
Ad ess c4..14/41 All eLO ky ,"2- /
Name of Funeral Firm Making Disposition or to Whom
1, S Remains are Shipped, If Other than Above
Address
t
(.L Permission is hereby granted to dispose of the human remai s described above s indicated.
z. Date Issued01-07-c2MV Registrar of Vital Statistics 1
sig ure)
District Number /go Place Village of Saranac Lake
;s I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r�
Date of Disposition {/1 l I Li Place of Disposition e. W
Clio(address)
W
IO
CC (section) (lot number (grave number)
pName of Sexton or Person Charge of Premises ,,�f , ��`�
Z ( ease print)
Signature Title ( Alfttt-
(over)
DOH-1555 (02/2004)