Martindale-Coon, Helen ,
NEW YORK STATE DEPARTMENT OF HEALTH �.� (,,Co
Vital Records Section w AL Burial - Transit ' ermit
Name First MiddleMiddle Last Sex
HL&V E : ,'►^► t '! L&. — Coc N F
Date of Death Age If Veteran of U.S. Armed Forces,
Ei
11'—(S^ (2-, 0 I War or Dates Ail
H Place o ath Hospital, Institution or
City, wnVillage Sv(n(NSa) Street Address ("1 '-7C Al (.l
to
0 Manner of Death 21 Natural Cause ❑Accident El Homicide ❑Suicide ❑ Undetermined El Pending
LU Circumstances Investigation
feu Medical Certifier Name Title
T W4n.av&7QA 01 )
Address
Death Ce - - ate Filed District Number Register Number
City, town o illage —504►I Se J►_/', �(U,S� 2 k
Date Cemetery or Crematory
❑Burial ( I (6, (& )(iv (,'(Cz:u G/4^^4- �f�,2-y
Address
:::::j.Cremation C ) u A u/. .V /1,�, '
Date Place Removed
0❑Removal and/or Held
-•• and/Holdor Address •
0
Q Date Point of
N❑Transportation Shipment
fl by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
<<;;i Permit Issued to Registration Number
diii Name of Funeral Home ( 5'al/ rJti,624L [ C 0 ( I( 7
>€ Address
/ C.7Q-26z 57 Ff° INA' . �' (2. .2 7
Name of Funeral Firm Making Disposition or to Whom
R• emains are Shipped, If Other than Above
A• ddress
W
tea
eii Permission is hereby granted to dispose of the human remai s/d�eescribed ve as indicated.
{ Date Issued 0,-(6—/z Registrar of Vital Statistics (V�.IXX�- .
11 (signature)
District Numbers( '- Place A�o _%�(wS L v>2C ! i-l-L(,
I certify that the remains of the decedent identified above were disposed of in +accordance with this permit on:
fi
WD• ate of Disposition II hell l('l Place of Disposition T iu V ct,,/ a v44 r'ovri-
6 (address)
f�
(/)
C (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises P,sk to n,•1II
z (please print)
04 Signature i ,l Title (YZtf Alj cXL
(over)
DOH-1555 (9/98)