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Germain, Ernest
NEW PORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First ., Middle Last ' Sex e_�1 c s r J16.5o ry GcR.ws 4 t 0 in Date of Death 1 Age If Veteran of U.S. Armed Forces, ©\ I Uo. �1515 War or Dates t- Place of Death Hospital, Institution or W City, Town or Village G LE N s fAL-`-5 _ ! Street Address Cy Le►-.5 FA cis 1--105 tT i A L_ `p Manner of Death xi NaturalCause D Accident D Homicide E Suicide U Undetermined C Pending Circumstances Investigation W Medical Certifier Name Title G} Lke ID`\ TET' r> kAi`L f'1 ' Q. Address Death Certificate Filed 1 District NumberT Register Numberqt./ City, Town or Village Cau.cNs FA�`S S ,C71 lBurial Date ! Cemetery or Crematory ❑Entombment - - --------- - -- ----__- - --_ __------c� ---- --- -_� Address Ucrerrration Lx r c,& C/ tv�t 5 ,r `1 a. s-0 ti Date Place Removed Z❑Removal and/or Held and/or Address Hold _- - — — — — — 0 ; Date i Point of ElTransportation f Shipment - 5 by Common Destination Carrier C Disinterment Date Cemetery Address • , Date Cemetery Address T — 0 Renterment ! Permit Issued to 1. Registration Number Name of Funeral Home t-i0„joaf c li. 1' t:I, ._e "L ner 1 i'oCY ! 1-! J i )C Address h L a-ct- y c fig . , Cam' -c n Yt.x_0 y , c .s lot- ..- 12 si(.3,-1 Name of Funeral Firm Making Disposition or to Whom �- _ Remains are Shipped, If Other than Above __ _ 2 Address 'CC d'` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued !/2 /_1_c' Regfstrat of vital-Statistics . (.' ) --_-^ r (signature) District Number 56 n Place 6 ( v`S -LL -� AV T __ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 2/2/1 5 Place of Disposition 21 Quaker Road, Queensbury, NY 1 2804 (address) 1.1.1 CDOneida _ 97 3 `c (section) (lot number) (grave number) --- - Connie Goedert e Con Name of Sexton or Person in Charge of Premises _ __.______—_, ._- (please print) , iti Signature Ln2. ______ Title ._ Cemetery Superintendent (over) DOH-1555 (02/2004)