Lanfear, Sherry j
NEW YORK STATE DEPARTMENT OF HEALTH
��8�� Transit Permit
Records Section
_{ Name Fir 4iddie L n)/�6 ,`--);T/7,6tzi
Date of Death t
67� I Age 1 If Veteran of U.S.Armed Forces,
ZfQ 117 1 7l f War or Dates 6
Plac- death " , stitution or
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15 Ci Town *r Village FT /dN,,J ` Street Address /�' O? . Q OBnr o '2yl
, Mann- • Death,RNaturai Cause 0 Accident 1-1 HomicideSuicide 11 Undetermined ending
Ltj Circumstances Investigation
fjj Medical Certifier Name Title nz
0 tiILC.J$l9 1de2_4 O S
Address / A
1 i 6/ Cfra.,61i ii-6
Deat ertificate Filed Di ict Number Reg 'ter N her
{ Citl,Tow .r Village FT pi L. 4 )S y S�
i Burial ; Date LCemet r r Cp)1Q
matory ) )
1 a/i7 CC UI ei-J CLM
❑Entombment Address /,----
❑Cremation u, 6� /24 0 uZ¢7.-J313v
( Date [ Place Removed
-1 Removal i and/or Held
:.. and/or Address
'= Hold
.0 ( Date Point of
ilon
Transportation I Shipment
as by Common Destination
Carrier i
`< ' L I Disinterment 1 Date 1 Cemetery Address
-i: E Reinterment I Date i Cemetery Address
!
Permit Issued to 1 Registration Number
Name of Funeral Home L C �E:. i"1 i-c'k\ �D j1� - ► 1 t 0
Address
: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
M Address
ID
• Permission is hereby granted to dispose of the human remains described above as i ed.
—
Date Issued 5- - o/ Registrar of Vital Statistics (�r "p��.,�� i -4f -t
/ signature)
District Number IJ Place .��Z G 27Z
q /;. S'_.-.7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' Date of Disposition 5/3 0/2 01 dace of Disposition
21 Quaker Rd. Queensbury NY 12804
(address)
W Erie 53A grave #2
= (section) poi number) (grave number)
1 Name of Se - n or Person in Char of Premises
Connie L. Goedert
z �Q (please print}
Signature . �+• - Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)