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Staunches, Thomas NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit PermitVital Records Section Name First Middl Last ` Sex Dn nS i\ S-koU1CVLO,srn Date of Death Age If Veteran of U.S. Armed Forces, R i 11_ I �' t3 ' War or Dates Place otDeath • 'anon or City Town r Village �`ue2r u r Street Addr QY1(o i Ve Man eath Natural Cause 0 Accident 0 Homicide ©Suicide El Undetermined Pending Circumstances Investigation W Medical Certifier Name Title U1i11a.rl c j-e-►/ Address /OD P09-n is Sr - ae-.)s fni ,tl 12 cP-O/ Death icate Filed D ict Number R aster Number City, ow or Village (Ue . lour ' 3 $un Date emete r Cre atory 7 24/I tk ,, []Entombment Address ❑Cremation a o aw b‘,._ Q 061r,..)5 a u/L`-' ✓ 7 , Date Place Removed Removal and/or Held and/or Address Hold I 0 Date Point of ❑Transportation Shipment 5 by Common Destination Carrier Q Disinterment Date Cemetery Address Reinterment Date Cemetery Address - Eli i • Permit Issued to Baker Funeral Home Registration Number Name of Funeral Home Address 11 Lafayette St., Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above 2 Address IX 41 Permission is hereby granted to dispose of the human remains described Ate as indicated. Date Issued I Registrar of Vital Statistics (signature) District Number --) Place 1 , Q LL Stm I certify that the remains of the decedent identified above were disposed of in acco •- h this permit on: US Date of Disposition 9/21 /2 01 8Place of Disposition Pine View Cemetery e -- sbury 2 (address) GO Horicon 24-A 1 CC (section) (lot number) (grave number) pName of Se tan or Person in Charge of Premises Connie L. Goedert 44 _Signature, �0?1ti..t.� _�I - � (please print) ..� Title Cemetery Superintendent � . �✓[ (over) DOH-1555 (02/2004)