Fish, Nan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name f.'ill,t Middle 1 Last ex
D- — �"1_S h ex rY fie.
Date of Death G Age If Veteran of U.S. Armed Forces,
Or LL L- _. 1 ) I9r1 War or Dates V\t��
lace of Death Hospital, Institution or 1 ' -
City, Town or Village GIef1S IS\ G,-y Street Address e.r b TI cOSp)'1-f�,
@I—Manner of Death Natural Cause I I Accident ❑Homicide Suicide 0 Undetermined ending
Circumstances Investigation
w Medical Certifier Name Title
C(oi -0 .
Address
Death Certificate Filed District Number Register jJu nbber
; City, Town or Village r�1 ens_ -1-c-\1S, NA) `jam p z
\ c
Date Cemetery or Crematory
. Burial �.hsL a3 Ickcn a - e\ S u S -
Address 1
u Cremation - _ t.xeer sbv..c 1rl 1 Zg3-
Date Place Re vedJ
C� Removal and/or Held
and/or Address
=' Hold
0
O Date Point of
11,4 h Transportation Shipment
O by Common Destination
Can ier
[I Disinterment ate Cemetery Address
n Reinterrnent Date Cemetery Address
Permit Issued to Registration
Number
Name of Funeral Home 1 � two-3 C. . Q\ '
«: Address
Name of Funeral Firm Makin Disposition or to Whom 3 D
u' Remains are Shipped, If Other than Above
ig Address
LU_ _
11 Permission is hereby granted to dispose of the human remains described above s in ' ted. -
Date Issued Z �3 ,`) Registrar of Vital Statistics 4‘ ,�f, r
(signa ure) c�
District Number 3IQD\ Place CA � G`,enS �Ct,1� ��' 1.D O
I certify that the remains of the decedent identified above were disposed of in ac'ectrzfance with this permit on:
f,^ Corner Pine St. and Luzerne Rd.
W Date of Disposition 6/23/97 Place of Disposition St. Alphonsus Cemetery, Queensbury, NY 12804
(address)
W cn Section II Row H, 28 7
(section) (lot number) (grave number)
to Name of Sexton or Person r Chmuge of Premises Rev. Robert W. Powhida
W
N� L (please print)
Signature Title Pastor
DOH-1555 (10/89) p. 1 of 2 VS-61