Connor, Peter 501
NEW YORK STATE DEPARTMENT OF HEALTH` ---4
Vital Records Section Burial - Transit Permit
Name First v� Middle`-i ' Last lr 0 Kik() r Sex
Date of Death Age a1- If Veteran of U.S. Armed Forces,
/n 7.�7 War or Dates
Place • •:ath Hospital, Institution or
City o •r Village itAitinsc,b tAmi Street Address
Man = '•f Death❑Natural Cause Accident 0 Homicide 0 Suicide Undetermined Pending
W. �"� Circumstances Investigation
Medical Certifier {dame 1 � ��Y Title
i 1 � (-Oro K_,r-
Address
S2 Nagy; I as . /9 v`e. �71-CM.s / /Vi /2?0 /
Death icate Filed i t r R ter Number
City, t wwp or Village pA1 1JL& ' D. >l 4 4
❑Burial Date Cemetery or rematory� ,
El Entombment l I I�-Q.. V I-CAvv
Address Cremation aVat-e/( t-e Q iA C bk4k1} !may .
1 Date lace Removed
Z91-1 Removal and/or Held
and/or Address
N Hold
0 Date Point of
Ahu)El Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
I
Permit Issued to Baker Funeral Home Registration Number
01130
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
2 Address .
CC
W.
43* Permission is hereb granted to dispose of the human a sins described abo e as indicated.
Date Issued (pc c)On Registrar of Vital Statistics - -�al isrl c...,,__
(signature)
District Numbee c'') Place ) o >r.s-,,r,a.-F d T 4
I certify that the remains of the decedent identified above were disposed of in a ••rda e with this permit on:
W Date of Disposition 712 //7 Place of Disposition 2/21 w, 6.,,eppi d.4ey
7 / (address) /
ILI
re (section) t (lot number) (grave number)
aName of Sexton P •n in harge of Premises J / '�✓t 64d4t ac
1 �f (Please print)
tiA Signature Title e-rerrtc /
(over)
DOH-1555 (02/2004)