Gould, Nelson NEW YORK STATE DEPARTMENT OF HEALTH' 1 53 Z
Vital Records Section Burial - Transit Permit
vit Name First Middle Last
Sex
"' Nelson A. Gould Male
,L Date of Death I Age If Veteran of U.S. Armed Forces,
06/29/2018 i 83 War or Dates
, „ Place of Death Hospital, Institution or
City,Town or Village Chestertown ( Street Address Deceased's Residence
Manner of Death Natural Cause X❑ Accident 0 Homicide El Suicide ,1-1 Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
MICHAEL SIKIRICA,
Address
58 BROAD ST. WATERFORD, NY 12188
Death ficate Filed i District Number Register Number
City, own r Village e'tLv' 56 5o 1
Burial Date . Cemetery or Crematory
A 07/02/2018
❑Entombment Address
In Cremation
. Date Place Removed
El Removal and/or Held
and/or Address
Ai Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
x,,, Disinterment
Date Cemetery Address
r:{{; ❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Xa Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
b Address
' 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
4
5
Permission is he eb granted to dispose of the human remains a 'bed above as indicated.
Date Issued 7(.2// Y Registrar of Vital Statistics ',t. 1)&.
5 (si tore)
District Number _,S) Place ( b i,w1 C C1&'s f-e
w I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
P
Date of Disposition 113 li¢ Place of Disposition .�U,i �rtM
(address)
(section) (lk number) r (grave number)
r Name of Sexton or Perso in Charge of Premises_ b sni tot*
io
P
(plea print)
u- Signature ' Title af4nUt
(over)
DOH-1555(02/2004)