Ethier, Rita NEWVl1171/STATE ru r * 9T11'tCI1IT OF LJCA I TLJ / # ZO I
Ill_WY IVItI S If11.L LLI PU%.1.tVEN I \J1 II' ^• .R11C U.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r'ra., r-.,..:..- r l
I ILO LII IIC.I t//T/_ f I I cI l lglc
Date of Death ! A�e If Veteran of U.S. Armed Forces,
1.N'F/VC.7/Lt!1 J p v val vl valca
Place of Death V Hospital, Institution or 6.0 /,F.. i— /0'
tw City, iOW*1i vi v,iiogeCliesier eopr - Sireei HUurebb ueueaseus Resruerwe
1rill
0 Manner of Death Natural Cause fl Accident n Homicide n Suicide n Undetermined t i Pending
CII LUI I Midi ILeb if IveSLI aiiur I
Ili Medical Certifier Name Title
i WiLLiAiVi C. ORLUK, RCi
Address
b223 State Kte 9 Chestertown, NY 11t31 I
e:4- - ..cate Filed ..,A,� i District Number Register tuber
Ci .r village
Burial Date Gemeter or Crematory-
04/08/2013 I P%/1--9 4e 2 ()ziii cc�Py�/41 A-I
❑Entombment Address
rj cremation -:_c(i_e � (/C • ,. 2 / e7 '-/
— ,Date Place Removed
zil ! Removal and/or Held
0 LJ and/or Address
tI/../.r
01_ I Date I Point of
a. u Transportation Shipment
0 by Common Destination
Carrier
i--i _. Date I Cemetery Address
U Disinterment
-- natl., Cemetery Address
Ju rceinierareni
Parmi} Ice;sari+n I C?aniotro}inn All ImF,ar
Name of Funeral Home Barton-McDermott Funeral Home, Inc. I 00141
4 ririraoc
9 Pine St/P.O. Box 455 Chestertown NY 12817
N-mc of Fur.crul Firm Making nisposi}inn or to horn
Lrr, � y � rvv...w..v.
Remains are Shipped, If Other than Above
�, nvul cJJ
u. Permission is here gr ted to dispose of the human re J ai des b ve a indicated.
Aanistr r of Vi}MI Cto}ic}inc $
Ddie issued "y •
(signature)
District Number cC- 5- Place .tAt-ita
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition IA'`-13 Place of Disposition -(..AJ4ruJ ere we ur;vA-
Z.I (address)
LU
co
ce (section) (lot number)( (grave number)
a Name of Sexton or Per on in Charge of Premises .,x
z l (please print)
{tt Signature 1, Title c e.611,,Avi,
(over)
DOH-1555(02/2004)