Combs, Ruby r 'NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
\mob'-‘, t,u 2_4. ,, c--1 14. G.,".cs s F
I Date of Death Age l If Veteran of U.S. Armed Forces,
D A l 'o / 1 S l a- War or Dates
Y Place of Death Hospital, Institution or
w City,Town or Village Street Address —
Manner of Death Natural Cause 0 Accident 0 Homicide El Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
CI v.a 5 k,y, SOLo\o m 0
Address ka264
I
Wcs; �av�\ �cALT�1 F/lLlLta� �� C� N r��
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Death Certificate Filed District Number Register Number
City, Town or Village c C rJS l.L.3� - SI'S t y
Date Cnetery or Crematory
Buri 4 al 0 ► ' ( a () C't�E \ �C`., cEv,1 S CR`]
Address
;::z ❑Cremation. ()-L.:,A ik-� e_ VoAD �E..N % .3 A7 t `"1 t % 9'
Date I Place Removed '
0❑Removal and/or Held
and/or Address
Hold
2 Date j Point of
Imo Transportation I Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
Permit Issued to �xt rd �czke� fpm� Registration Number
f
Name of Funeral Home Fu.ner oil 30
' r Address Ir Lc.fa /RO <. , r�cdte eisbU j ,Neck (krAL 1 a gC-/
r e
4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
V
r. Permission is hereby granted to dispose of the human r ains described.above as indicated.
5 Date Issued Li l I'c- ("cRegistrar of Vital Statistics 4^�-Cf.At— C( , d\�1,t.,�
A (s ature)
61 District Number S(9 cn Place Itom, CYr W lJt P-a—Tv4j
I certify that the remains of the decedent identified above were disposed of in.acc�e/dance with this permit on:
P�
f Date of Disposition 4/1 6/2 0181ace of Disposition 21 Quaker Road, Queensbury, NY 12804
(address)
SA Hudson ##1 31D 1
Cr (section), (lot number) (grave number)
0 Name of Se on or Person in Charge of Premises Connie L. Goedert
2 (please print)
Signature IttL `�- -1-P ivc Title Cemetery Superintendent
(over)
DOH-1555 (9/98)