Bacas, Elizabeth i
- NEW YORK STATE DEPARTMENT OF N±e,ALTH` r
Vital Records Section Burial - Transit Permit
:! Name First Middle Last Sex
Elizabeth Bacas female
Date of Death Age If Veteran of U.S. Armed Forces,
02/07/2006 73 War or Dates n/a
} Place of Death Hospital, Institution or
Town ibffiltak Queensbury Street Address 9 Cedarwood Drive
▪ Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide ri Undetermined n Pending
USCircumstances Investigation
iii Medical Certifier Name Title
William Borogs, MD
Address
14 Manor Drive. , Queensbury, NY
Death Certificate Filed District Number< Re7ista Number
<<X�Dfy, Town oXXl ItfX QUeensbury 5657 (�
,A❑Burial Date Cemetery or Crematory
jj ❑Entombment 02/08/2006 Pine View Crematorium
Address
' EiCremation Quaker Road, Queensbury, NY
Date Place Removed
K.❑• and/or
Removal and/or Held
} Address
Hold
0 Date Point of
NQ Transportation Shipment
O by Common Destination
Carrier '
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address .4
Permit Issued to . Registration Number
Name of Funeral Home Sullivan-Minahan & Potter Funeral Home - 01734
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
IL
ILI
a Permission is hereby granted to dispose of the human mains described above as indicated.
Date Issued c l �, )0(0 Registrar of Vital Statistics 1j-( _-. (Y) kArL.
(signature)
District Number S(QS---) Place (___,_r.1 43.,--,-,
I certify that the remains of the decedent identified above wee disposed of in accordan ec vith this permit on:
��' p
I�• Date of Disposition �.-i -G,� Place of Disposition 9) Al>= 1Ji�`t{,} �,i��,M,`l'�'DR..'i V,�/,
a (address)
a
Ili (section) (lot number) (grave number)
▪ Name of Sexton or Person in Charge of Premises �p?Z-i1 (�t�.4/�
.2.. (please print)
Signature (,vy Ji +i Title 1►a-t`O Z_
t/i�
(over)
DOH-1555 (02/2004)