Barrett, Danny it tzui
NEW YORK STATE DEPARTMENT OF HEALTH.- %-
Vital Records Section Burial - Transit Permit
Name First . Middle Last Sex
OM aiu Le 4kte r3cidrret;t- lin
i-A Date of Death, i I .... Age If Veteran of U.S.Armed Forces,
ii
''' : 101 I( iii 7 (P7 War or Dates --
tiii; Place of Death , Hospital, institution or
a City=-Lililage 1-110-C-Ord 1 Street Address 5 g9 S+.12-±. 1%
149 Men aNatural Cause E)Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
C.) Circumstances Investigation
Medical Certifier Name Titlik
Pi ..11 it c- 1 Q /9/0 T7-7 — c(z,u-ii 4-S
, . Address
i 0 7._ e„,,, 7 c,„ , , Fa,,,,,,i,ivy 1 a e oi
. t
„ Deallficate Flied _.1 1 District Number‘5.1 s-9 L Register Number
111 City, ow or Village tor cc" - - i I I
,- .11:113urial Date Cemetery mbment or Crematory r-,7)
... 161 fe- I rinaVi mereartory
,jEl' Ento
Address ..... .......i.
Cremation GOar--e-r ' --OCCI, 0 legnshury ,i,-) 1 12ft5.LI
•Removal Date Place Remo‘M
1:1 and/or Held
anWor Address
Hold
Date I Point of
ppf,.gt D Transportation i Shipment
Ic1i-f,p, by Common Destination
; Carrier
.•1 0 DisAteyrnent Date Cemetery Address
::.,. F--;_
A rment Date Cemetery Address
Ieinte
Permit Ise ed to Registration Number
Name of Funeral Home Baker Funeral Home 01130
i
•
i Address •
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
tr.,' Remains are Shipped, If Other than Above
Address ....
40 "
,- P& •rission is hereby rented to dispose of the human rem desaitiked indicated.
;:...'
Date Issued to / k Registrar of Vital Statistics t .
fidenature)
District Number 51 S \ Place Alk 14-CC),{A M
I ceratl; that the remains of the decedent identified above were disposed of in accordance with this permit on:
.....--i
..-..
..,. Date of Disposition /0 i ,fig ii Place of Disposition
&ff
gt
(section) . Pot In7bed
—)
(grave inanber)
Name of Sexton or Person in Charge of Premises i A ft_....-- bil
(please • t)
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6
fILI' signature . -.',C7 Title • /17k/Alln,g_
(over)
r D1-44556 (02/2004)