Ordway, Stella Marie NEW YORK STATE DEPARTMENT OF HEALTH -
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex f
.;-e\\q r(10\r\ 2 . OY( AiO. 1—
Date of 2 Death Age If Veteran of U.S. Armed Forces,
Mii 11-1 ) LC7`-\ T,C..i- War or Dates
fi ., P - of Death Hospital, Institution or n
Town or Village �r end Gvy 'm . Street Address B�. VY1�`3 -1v- ) J�-t` -
anner of Death L. Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
La Medical Certifier Name Title
O JG, r\ -e5 C\ncAc,- k . ►'YD .
Address
Death Certificate Filed District Number Register Number
iM City, Town or Village
❑Burial Date Ce etery or Crematory
--2- \2-2120Z0 . V,rNr2._ Q\ew CreMcd-vYv+
['Entombment Address
Er remation
Date Place Removed
❑Removal and/or Held
and/or Address
= Hold
Date Point of
Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Ni Permit Issued to ,n Registration Number
Name of Funeral Home I-1eXc( Q -. vfQ rca Hoy\,-Q U Q .rl . -
Address
5(a. O rna "jr. u rer-Tbvr
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
tr
L
9" Permission is h reby granted to dispose of the human remains described above as.• •mated.
Date Issued Z 181 2O Z)Registrar of Vital Statistics `J c
(s re)
iliv, District Number --ea() Place C' A o f AmTh{e a on(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition 2111 f 2( Place of Disposition �,,,�(L L
(address)
Lu
cc (section) (lot nurTber) (grave number)
Name of Sexton or Person in Ch rge of Premise `lt t'i+ t �M^ dd" "
(please print
Signature Title 10004TA2
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 014i5EC
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#