Young, Theodore NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Kermit
Name First^L�_ 11�e— Middl Last Sex r,
1 I �U�nO
Date of Death Age f Veteran'df U.S. Armed Forces,
Li11,2. I t e _ 2 War or Dates (q — f ,(Ce.
Place Bath Hospital, Institution or
City Towfi or Village ( ()a n y)U Y - Street Address y 4 ]E))0.4)�) �vk ear f Q g'
Menne of Death Natural Cause ❑Ac4dent 0 Homicide Suicide Undetermined n Pending
US Circumstances Investigation
ui Medical Certifier Nameeev�S Title'(`N
Address
Deanyc. cate Filed District Number Register Number
City, Town Village Lo 5 1 Li c(
6GiBurial Date y l P g 1.01 1 ( Cemetery or Crematory i e � ,V7Le
DEntombmer t Address
i i ,rj
QCremation V, S t2v Y - (��/' 12S'b`I •
Date Place Removed
Z 0 Removal and/or Held
gi., anHoldd/or Address
i'3+ Date Point of
L i Transportation Shipment
to by Common Destination
Carrier
• 0 Disinterment Date Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Baker Funeral Home 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, if Other than Above
Address
> Permission is hereby granted to dispose of the human remains described above as indicatsd. _.
Date Issued Li -t - (At)1 ' Registrar of Vital Statistics —'Q-4-AA -'(/ p Q__5,,t 1
(signature)
District Number tv S 1 Place O u t.e r1 S h V
,3
I certify that the remains of the decedent identified above were disposed of in ac rdance with this permit on:
it Date of Disposition .I I) ) ,Q) Place of Disposition 2 I4,vd,u,t, L.
(,k° ,, (Yc
z,),
(address) 1
CO - ,tf-tail• 20 a A 2
(sp Vn) (let umber) (grave number)
ita Name of = 4vn or Person in Charge of Premises ( _c A h_i e L• &�-
z , • se print) ,
41 Signatu �% . _ 6yeek/rcTitle ♦ ..0 1 t/L
(over)
DOH-1555 (02/2004)