Dufour, Madeline NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Middle Last Sex
Name First DuFour P
Madeline F .
Date of Death Age If Veteran of U.S. Armed Forces,
12/14/98 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village Town of Delhi Street Address Countryside Care Center
Manner of Death®Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Laura Chalfin M D
Address
Main St. Delhi , NY 13753
Death Certificate Filed District Number Register Number
City, Town or Village Town of Delhi 1254
Date Cemetery or Crematory
❑Burial 12/16/98 Pineriew Crematory
Address
Cremation Queenshury, NY
Date Place Removed
Z ❑Removal and/or Held
and/or Address
v5Hold
Q Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc. 00224
Address
24 Church St. take Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:XXPermission is hereby granted to dispose of the human remains escribed abo as indicated.
Date issued 12/15/98 Registrar of Vital Stati
TO OF DELH ature)
District Number 1254 Place 5 ELM St.
i certify that the remains of the decedent identified above were disposed of in accordance w-itch this permit on:
W Date of Disposition .�c`/r Place of Disposition !`/t/ .� - 61ZZ F/-' 707 410-7
..2 (address)
LLI
(section) n (lo nu ber (grave number)
GName of Sex on or Person in Charge of Premises . 17�V��1 D fi 1,4-
(please print)
IU Signatur Title .�iG �? r
DOH-1555 (10189) p. 1 of 2 VS-61