Blair, Michael 't7tl
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
ti i c H O-L=1- )4rmi,> -X IA",it_ i 103.,c1
Date of Death 1 Age If Veteran of U.S.Armed Force,
/a 1! ill) _ IP2- ,A)/6War or Dates ,A)/6
1.0 Place of Death �/ Hospital, nstitjor
. '1 CityTown o Villa e �1y�:G t ,J c�J/ . se ) Street A cress ►v i n.5 , C-C^'i 4\—
, Undeterm ed Pending
rao Manner of Dec Natural Cause [�Accident [�Homicide [�Suicide [�
rill. Circumstances lnvestigabon
Medical Certifier Name Title
li 1/0--36.-ic r! . Ll aLo M
Address
nn t by l 2,033
Death Certificate F'ed District Number Register Number
City,Town o ilia L+03;[,vim,..) o,J/7UOs a..� Air i if _ 3
❑Burial DateCemetery m Creato
Entombment t O I
i),„; Uf'1"A")
Address
SQremation 0 u x 'K 1,ti,., /iliJ. ( v �0 ,i 3 y
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Baker Funeral Home 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
x.= Address -
MI
Permission is hereby granted to dispose of the human _ sins d. cribed above as indicated.
Date Issued /D f/7//'7 Registrar of Vital Statistics j' aJ ,
( nature)
District Number 1))3 4 Place ea 4np .. .pay` ,�)) PS7 V _.p
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
riii Date of Disposition /QJ l?I i) Place of Disposition oxo ( ,..•
i (address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises /Ar' L e4
.44
(please print)
Signature u Title
/►'liAllP,r
(over)
DOH-1555 (02/2004)