King, Theresa A
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transjt lieffiiit
1 Name First Middle Last I Sex ,
1\l-ec.e a., t-'t Ct r 0. nl vnci
Date of Death Age I If Veteran of U.S. Armed Forces,
i a\'3 1 act 57 I War or Dates
I Place Death Hospital, Institution or
3 Ci ow or Village (... .A-e-enShc.�r Street Address J Oh I'O
faManner of Death N T Natural Cause Accid It n Homicide �Suicide �Undetermined ri Pending
W 'f� Circumstances Investigation
pw_ Medical Certifier Name Title A , ,�
a fir . S t - loot (`�t,J
Address 10Z Pcr. ik- U f -/ CD ./t.0 rallA,,AH /Z 70
Death Certificate Filed ,,., b D c.t er Register Number
City,Tow�n or Village . C ( ,
%Burial 1 Date CemetP!()
.or Crematory
Entombmen#) /Zi I n Vi o. ) Cei')i e
Address
❑Cremation
r _Rood 7DttP nsbiyy >>/i -or k_ / y
Date i Place Removed
Z — Removal I ; and/or Held
9. —and/or " Address
, Hold
Date Point of
iffil50 Transportation Shipment
a by Common Destination
Carrier i
C Disinterment Date Cemetery Address
:, I 1 Reinterment Date ! Cemetery Address
>< Permit Issued to Registration Number
Name of Funeral Home -.\/:\C=_� �,,li; x\ hoc \ - C t 1 ?0
Address
t
Name of Funeral Firm Making Disposition or to Whom
I4i; Remains are Shipped, If Other than Above
Address
CC
w
:': Permission is hereby granted to dispose of the human rerrOns described a�b�ovve as iyndicated.
Date IssuedI c�l Li? I�)lpRegistrarof Vital StatisticsL G �s� �1�---__
(signature)
District Number 0 Place LA•_� S1.7) J
iZ I certify that the remains of the decedent identified above were disposed of in accord nc with this permit on:
lit Date of Disposition 1 2/9/201 glace of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
ili
Uncas 1727 3
E (section) (lot number) (grave number)
nName of Sext or Person in Cha a of Premises Connie L L. Goedert
%� (please print)
Signature Sze- .',-/i Title Cemetery Superintendent
f
(over)
DOH-1555 (02/2004)