Rafferty, Michael 0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle t Sex
Ili G//B-Z�Z ? ti !file— 1 //OZel
Date of Death / Age If Veteran of U.S.Armed For ,
• s- j //> I 9 9 War or Dates /9S? _ ) 9 9 r
i- Place th Hos itaL.Institution or
F City Town Village h c,/y be- reet Addi y 8-1 to o-J% Roo 6r Li7
Manner ofi Death, Natural O ❑ ❑ ❑ ❑
use Accident Homicide Suicide Undeteined Pending
tki Circumstances Investigation
w Medical Certifier Name Title
CI S'7y61-13 1y Dl iti. i .
Address
I / 3 110i,c. 11.E AT, ,J,' .6,iv iU /z2o6'
Death ertificate Filed : District Number / Register Number
City, ow ,r Village 172 a t e- Sri S v , I o
{ unal Date - Cemete rRremato
if
DEntombment
Address_
[Cremation CZ ,,A-rt t,ti.- ? Q 17 ;to s a u /U -
Date t Place Removed
ia❑Removal I and/or Held
_. and/or Address
Hold
rn
0 Date Point of
fk❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
-
' 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
h Remains are Shipped, If Other than Above
2 Address
ILI
#` Permission is hereby granted to dispose of the human remains described above as indicated*
Date Issued S'31 j y Registrar of Vital Statistics &AM.L. -
(signature)
District Number 5 7 Se Place II-�y i i L
f I certify that the remains of the decedent identified above were disposed of in accordance with this permit an:
W Date of Disposition 5/7/2 01 8 Place of Disposition Pine View Cemetery
(address)
ill
CO Huron 28-C 1
CC (section) (lot number) (grave number)
0 Name of S n or Person in Charge of Premises Connie Goedert
z (please print)
•Signature 1144.0 �-(312 Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)