Nofi, Charlene NEW YORK STATE DEPARTMENT OF HEALTH ' 2 6%
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Charlene Nofi Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/22/2012 53 War or Dates
W Place of Death Hospital,Address
)ry �`�J V 7
City, Town or Village Chestergicrt Street Address lv U
WManner of Death J Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
III Medical Certifier Name �� Title
CI WILLIAM C. ORLUK,
Address
6223 State Rte 9 Chestertown, NY 12817
Death Certificate Filed / - T e' District Number Register Number
G f City, Town or Village /-- � r,�)___. 46?..,,
®Burial Date or Crematory
El Entombment 05/24/2012 ean''/?Q (�L-P C/e/ ct�l t��,
Address �Jce / � (1- /iZ O
❑Cremation ,�} / y��� c�
Removal Date Place Removed / -� /
z �• and/or and/or Held
F. Hold Address
a Date Point of
aEl Transportation Shipment
N by Common Destination
t] Carrier
riDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
W
O. Permission is hereby granted to dispose of the human r m 'ns d cri e e asl(ndiKated.
Date Issued /o(3//aL Registrar of Vital Statistics • ›Lr
(signature)
District Number n(p�r-' Place (4‘.�'lic. C4 v��Z /v';g/ 7
•
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition rhyla Place of Disposition ,iA I,r,,,
ill (address)
co
I4 (section) /� (lot number) c (grave number)
O• Name of Sexton or Person in Charge f Premises L hr�)���r J�c�1
z
8 (please print)
W Signature Title C 0t-
(over)
DOH-1555 (02/2004)