Hughes, Mildred NEW YORK STATE DEPARTMENT OF HEALTH _ 4 73 0
Vital Records Section ` . , Burial - Transit Permit
Name First Middle Last Sex
Mildred 3. Hughes Female
Date of Death Age If Veteran of U.S. Armed Forces,
ac
Oo'f�e� years War or Dates
ath 91 Hospital, Institution or
iiiiw City, . •e Street Address
ga Man =' . a-.',o Glever's�"He Mountain l�xtc-Iosice
W.
• Natural Cause Accident Homicide �Suicide etermined ❑Pending
Circumstances Investigation
Lij Medical Certifier Name Title
Aidoressl R. Bcll MD
Death Certificate Filed District Number Register Number
City, aft a { ge Gloversville 1701 116
❑Burial a e Cemetery or Crematory
0 Entombment Addres 4/22/2013 Pine View Crematory
` ]Cremation Queen_bu NY
Date c ry' Place Removed
Z❑Removal and/or Held
and/or Address
L7 Hold
tf)0 Date Point of
ti Q Transportation Shipment
C by Common Destination
Wi Carrier
>; El Disinterment
Date Cemetery Address •
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
24 Church St Lake Luzeme, NY 12846
Name of Funeral Firm Making Disposition or to Whom .
Remains are Shipped, If Other than Above
a Address
i1
ill
K` Permission is hereby granted to dispose of the human remains scribed above as indicated.
DE Date Issued 04/22/2013 Registrar of Vital Statistics ,�,r, ,�,—y-fL
(signature)
District Number 1701 Place Gloversville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 14' Z313 Place of Disposition P,,,Vgt,a �iwrwc¢otsu+--
2 (address)
UI
0
11 (section) ` (I t numberk-� (grave number)
Name of Sexton or Pers n in Charge f Premises �r'� •- JD+^�
lease print)
Ili Signature Title C94 iii-W.,
•
(over)
DOH-1555 (02/2004)