Malcolm, Norma s
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit PermitVital Records Section
Name First Middle Last Sex F
f\J Or-rn Ste. 4 AA) '1 \C1 C vv-N
Date o Death Age If Veteran of U.S. Armed Forces,
Si / & q i War or Dates
y, d Place eath Hospital, Institution or
`""r City,t r Village ill ue.c ?_5:_h V ri Street Address 1 1 /
rat Manner of Death Undetermined Pending f'
atural Cause 0 Accident Homicide Suicide [�
Circumstances Investigation
n1 Medical Certifier Name Title
e.r\ i Pev L . Strati: n 'v)
Address
l‘ l Cav" EGO,__CI a e ev15\5U r . U , / c9- a
Deatn_Cattificate Filed District Number [Reulster.-Nurnber
City, own)or Village Q U e e 1 S I i r c
bBurial Date Cem tery rematory' '
DE ntombment -v-- :,1 i ,1- 41 ._ _ I n e U t �. \--)
Addr s n
[]Cremation uc k e. ir— e00,6 nQ e e_v-) j lQ U `tr LI
Date Place Removed
--1❑Removal and/or Held
and/or Address
Hold
Clil Date Point of
1 Q Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Renterment 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
Remains are Shipped, If Other than Above
--=j Address , ..
Fli
Permission is hereby granted to dispose of the human remains described•b as Indicated.
Date Issued3 I 1 Jl V Registrar of Vital Statistics '6-�. C �t
r— � (signature)
District Numbe[ Co Cal Place 1 U L,--- , -
I certify that the remains of the decedent identified above were disposed of in acc• •: ce 1 this permit on;
I I Date of Disposition �(f
I Z(ZA I t Place of Disposition Z c ' ram; ,
ttt S t ,. 7r.ss)
1-1
.., on) c (lot number) (grave number)
Name of Se n or Person in Charge of Premises l (E • i
.(haasio Print}
Signature OW -• Title -15
641
(over)
DOH-1555 (02/2004)