Fitzgerald, Mary NEW Y0RK STATE DEPARTMENT OFHEALTH ��UU�~%�U � ���%�����~� �����M��~� �
Vha| Records Se��n ��==° "~~° ° " ~~°°~=n� Permit
Name First Middle Last Sex
Date of Death
Age It'Veteran of U.S.Armed Forces,
88 War or Dates
Place of Death Hospital, Institution or
---- City,Town or Village Queensbury, NY Street Address
Natural Cause Accident D Homicide El Suicide
Circumstances L-J Investigation
Uj call Certifier Name
Bernardo R. Villajuan, M.D.
Address
City,Town or Village Queensbury, NY 5657
Burial Date Cemetery or Crematory
Ky
z Date Place Removed
2 Removal and/or Held
Fn Address
` -__~______.__~^ __ ___-.___^- ___.-____-__-__'__-'___--__-_-------/�^ -- Point of
_w []Transportation -
Shipment
x� Common Carrier
-------------- ' - -' '
Destination '
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_.___________, '____-'�����__ .............~___-_'_____---_
' �7D���vm*n Date ~'/Add'e~~
' .......................................... ~~..~.`~-_^~-~-`-~ ^~''^~.~~~...........~~~^_~~~~-.~.~~.~~~^^~
� F7 Reintement Date Cemetery Address
Permit Issued to
Registration Number
Name of Funeral Firm James F. Singleton, Inc.
0182.5
Address
:2. Remains are Shipped, R Other than Above
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____ ..................................... __ ^- '-_- _ /-----� - -- ' ---'------------------^----�N� /
Permission Is hereby granted to d| a d�o 'd.
Date Issued May 3, 1993 Ra0��ar �V��
--- ` \
�& Distric Number 5057 Place Oneenoln�ry, NY
-
� |certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
_ /
� Date of -��-�_� P�ceufD��mh�n
:e (address)
W
Cn
cc (section) (lot (grave number)
a N ofS Re ^�.V
(please print)
LU Signature Title 70 /�r--
~~,.~~~~~...................................................^__----'-^..........-'~^.................................. _�~°'~-''~'......_~...-'_~- ......
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DOH-1555 (10/89) p. 1u/2 VS'61