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NEW YORK STATE DEPARTMENT OF HEALTH Burials Transit'Permit
Vital Records Section
Name First Middl Last ` Sex n „
JCo �t LL)J9 S IV 1
Date of Death Age 1 If Veteran of U.S.Armed Forces,
Z I
(1 Z o 1 1 War or Dates
H Place ath I Hospital, Institution or y�j ec Le Qcx k C i cc vz.
5 Cit .Tow or Village Q uzens}, ,;� i Street Address R 1c19 _ _2_
p Ma f Death fllr��l Natural Cause D Accident 0 Homicide Suicide determined Pending
ircumstances Investigation
l Medical Certifier Name 3Uh n S` 7Ju .nbu cs Title or
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Address JO L pax k S.-_ L texiis f a i r (Z
Deatp C rtificate Filed i DiWict Number Register Number
City(Town r Village Q V( ''�Sr3 v 1 ( - I, ( H Qj
Q Burial Date 1 ) I Zs/Z o l '} i Cemetery or Cremate i , c�1't.�2 V i 2� are iT1Gtl'0`��
Entombment Address
,Cremation kjuCk.ICAY Q06\ei Qv-e-enCbk.)r l J '... 0LJ
Z Q Removal Date Place Removed
and/or Held
2 and/or Address
Hold
CA
Q Date Point of
c[l Transportation j Shipment
0 by Common Destination
Carrier
[�Disinterment Date I Cemetery Address
Reinterment } Date I Cemetery Address
Permit Issued to I 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
2 Address _ ;
EC
4L1
41' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued \k . l301 ) Registrar of Vital Statistics . (
, (---)e ,„_________
t (signature)
District Number IS'l Place I C`j w7-,, (!)-
l I certify that the remains of the decedent identified above were disposed of in a ante with this permit on:
Ili Date of Disposition Ii I3M in Place of Disposition U.s t vtvr
Ids (address)
(/3
IX (section
0 ) (lot number) (grave number)
Name of Sexton or Person in Charge of Peemi es ( Sn,.41
2ili
(pase print)
Signature Z . Title !ii i A�m rtCiN-
(over)
DOH-1555 (02/2004)