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Caldwell, Helena NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section iM Name First Middle Last Sex .:.:.. ..:.:.:........... ......: Date of Death Age If Veteran of U.S.Armed Forces, War or Dates March.. . .1: _.......... .. ...6.8 ...::. ..: no ::...:..............:..................:.... :: .. . .. :: : t Place of Death Hospital, Institution or ::.!iiii City,Town or Village City of Glens falls Street Address 18 Spring St. id Manner of Death ❑x Natural Cause ❑ Accident ❑Homicide Suicide ❑ Undetermined 0 Pending itt) Circumstances Investigation la Medical l Certifier Name Title ©.:.:.:...::........:...W.i.11iam..:A; Tedesco...:.....:. ..... Address 3 Iron ate Center Glens falls, New York Death Certificate Filed District Number Register•Nu ber ,City,Town or Village City of Glens Falls 5601 / ) Date Cemetery or Crematory ❑Burial March 19, 1991 St. Alphonsus Cem. ..:............. ❑Cremation Address Tn. of Quccnsbury z Date Place Removed .0 0 Removal and/or Held i— and/or Hold ::::. Address Cl) D. Date Point of N' 0Transportation by Shipment p• Common Carrier Destination .............. Disinterment Date Cemetery Address El Reinterment Date CemeteryAddress Permit Issued to Registration Number Name of Funeral FirmSullivan Minahan and Potter Funeral Home 01933 Address 67 Park..St:.:.Gl . ens...Falls,::.New::.York.:::::: . .... ................:.. .... .:.. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above : Address AW . ' Permission is hereby granted to dispose of the human remain describe above,as indicated. Date Issued / y/ Registrar of Vital Statistics ,. , L A...„1 - /2 ignature) District Numbet9&Q Place /� / /27/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z, Date of Disposition 3_4/1 9/91 Place of Disposition St. Alphonsus Cemetery, Luzerne Rd. & Pine St., g (address) Queensbury, NY 12804 w Special Section "D" 111 1 cn cc (section) (lot number) (grave number) 0'' Joseph A. Falletta p Name of Sext or Person in Ch-rg- f Premises P Z (please print) W' Signature ` �li� Title Pastor DOH-1555 (10/89) p. 1 of 2 VS-61