Coon, Eleanore ! 'J (c
NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transit Permit
Name First Mi dle Last Sex
E Ie�v\j Lr e o��se LA C rek
Date of Death Age If Veteran of U.S. Armed F ces,
g—z --/5 bU War or Dates /U
}- Place of Death Hospital, Institution or
City, Town or Village SC U�j a SQ „ Street AddressIII ° bleAsp-
Manner of Death Natural Cause
Accident
Homicide �Suicide Undet rmined Pending
Iii �
' Circumstances Investigation
tu Medical Certifier Name Title
n Ur, jkl&-t q Q ✓I_ /YI 0
Address atAA rrL. S- ! 2g66
Death Certificate Filed SARATOGA SPRINGS District Number J/ Register Number
CiEXown or Village 7- 0/
❑Burial Date �l , j CemeteryQr.Crem(atlory f,,,
El Entombment (,j /WI e th` (_./eGv�a-
Address Alf)
Cremation �-C( U&i.XY,✓- d O(4(eQ1 .$ 6E.,f �y N`
Date Place Removed ✓
❑Removal and/or Held
and/or Address
i= Hold
0 Date Point of
i Transportation Shipment
ct by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date . Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home C(ry, Y,,,/�<5 5(O*S A,L yNej-c ( ti(e CO 5 /9
Address tie)2 ka /l iJ'e $ /Vrr 5 j / t�jC .
Name of Funeral Firm Making Dispos ion or to Whom
Remains are Shipped, If Other than Above
a Address
1
W
Permission is hereby granted to dispose of the human remains des ' d a ve a_s�'ndi ted.
Date Issued g--,2?-- 0 Registrar of Vital Statistics I •
3 (signature)
1. District Number //so/ Place SAR 1 T C A SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Cileorinizog
ILI
Date of Disposition�� Place of Disposition �i�J�
(address)
ILI
f3
I (section)` /�'Y #(lot number) (grave number)
CI
CI Name of Sexton o - on . - • - • Premises
ear ♦ Ad 06.40= )rint
Signature ,d >4 ‘51C— Title
(over)
DOH-1555 (02/2004)