Goldbecker, Caroline NEW YORK STATE DEPARTMENT OF HEALTH �U G'
Vital Records Section IF - , Burial - Transit Permit
Name First Middle Last Sex
x Caroline S. Goldbecker Female
:Ai Date of Death Age If Veteran of U.S.Armed Forces,
As
07/30/2014 _ 74 War or Dates
Place of Death Hospital, Institution or
City,Town or Village Brant Lake Street Address Deceased's Residence
Manner of Death Natural Cause 0 Accident �Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
+fi Medical Certifier �,�me6 y
j Title
CY///r/- / /
":, Death Certificate Filed District Number, f/ _ Registers Number
Eitg;Town or Wage -Po r i C 57p - �'
-_ ❑Burial Date Ce tery or Cre a ry c---
❑Entombment 07/31/2014 _� 1 P� C/Q,6 -"—
,4 Address jjj////
®Cremation 4/6, :e-7 v,,,ef �l' �� %'
Date A
lace Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
,y Carrier
i Date Cemetery Address
*,� Disinterment
fa Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
P Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St I P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
tea; Address
1
h Permission is hereby granted to dispose of the human re ai described ve s Indic ed.
r� `,-t/
_£t Date Issued /- 3 i,/ Registrar of Vital Statistics
N
(signature)
x34,4
434 District Number Place ..`
Mi
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
, Date of Disposition 7-3/ Place of Disposition 0/`iIt- (/I 0,� 111fC `.
(address)
(section) (: _/A) (lot number) (grave number)
Name of Sexton Pe o . arge of Premises (X,-`{/f ��
��,
(please p 'nt)
1 �C%Signature i Title -f
(over)
DOH-1555(02/2004)