Bombard, Michael Il $07
NEW YORK STATE DEPARTMENT OF HEALTt-I `" t Q -t�
Vital Records Section s Burial - 1 ransit Permit
Name First y Middle 1..mt ' SeA
/ i i cee z At",O '-3 LSon IS ' / 7.t.(i
Date of Death ( Age I If Veteran of U.S. Armed Force] ,
I /0 /2�112 (03 j War or Dates 4/i'
i- -ce of Death I Ho •' - + titution or ,/ (�
Allepy own or Village r,6,,)s �-Z.LS Street Addres / L( .!7 o n-i..) vim.
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IAZ ll Tanner of Death Natural Cause a Accident ❑Homicide Q Suicide ri Undetermined Pending
Circumstances Investigation
la Medical Certifier Name Title
0 1. ,�V Fcote- 1l /)_
Address ?UU + y akn S - , *l Son (=-a.-I 1%, (.i `-/ 12 g 3
` D h Certificate Filed 1 D s rict Number : Register Number
CCit;;Vrown or Village Li Le'Ais Fbu
QBurial Date Cemetery o Crematoit
/0 �3(/)7 ri,o tt- �e �---3
.Entombment Address
temation Q va'►L&'-.. t Q J, ,Js II WSJ .
Date Place Removed /
Q❑Removal and/or Held
and/or s Address
(A Hold
0 Date Point of
h
0 Transportation f Shipment
L by Common Destination
Carrier
Disinterment Date I Cemetery Address
El
Reinterment Date Cemetery Address
Permit Issued to Baker Funeral Home I Registration Number
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
-'- Address -:
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Lu
41 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (0)30 jzo i 7 Registrar of Vital Statistics C1JO,A,Ltv\9 (/JAA'rC,471
} (signatu
District Number 5 ��o I Place 6 l vs ( I s, 6kf t)
l- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition it t3[in Place of Disposition 1 ,0,-., G hovel-or,,,.,-,
2
W (address)
(I,
tr (section) (lot number (grave number)
pName of Sexton or Person in Charge of Pre ises S':.. wt
Z ( se prin
W Signature 2t �, Title ln£MlN-
(over)
DOH-1555 (02/2004)