Gilman, Shirley t 'NI
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First c 1 Middle Last . i Sex r-
-
: J Iv ke vc.k
Date of Death I Age , If Veteran of U.S.Annisd Forces,
.:,
03 kit j)1.1 57uej,n y War or Dates —
pi; Place o Death Hospital, Institution or
City or Village cburq 1 Street Address
IA 10 D rourThc,\ re.e. f-
man DeatnoNatural cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0PerKik.19
.10 Circumstances investigation
Medical Certifier Name iN A Title
lit ' Kum IAD
9:-
..-.2 . Address „ i
.F.:
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".1 111 "IC jj. Ci-t 6(0\ ra,11.1 1 ,A)L1 I 2 %Di
Death Certificate Filed Die,triAlklumber Register Number
or Village L.3/lAQ..0‘4 -b--LA•t--1 L9C n 1_ 1 (0
Burial Date ). (r ' Cemetery or Crematory ,,,-) v
f!,,:'1‘1•`,.. r- ' -
) 63 L? , p.
v7Ps c .., k_aryuAtLy,)
Entombment Address
Cremalion
• L_____ _. GUcute( te'd 4. (,)ue pin D u r CI j••. '.4
Date Place Removed -1 -
M•1--1 Removal
iii41 L_J and/or Held
.... and/or Address
Hold
r49-1J
4.. Date Point of .
.§-irD Transportation Shipment
-,.---, by Common Destination
Q
Carrier
Disinterment Date Cemetery Address
. J-1 .
Fienterment Date Cemetery Address
...,ID
Permit issued to Registration Number
Li'.'...i. Narila of Funeral Home
... i Address
Baker Funeral Home
11 Lafayette St., Queensbury, NY 12804
Nam s of Funeral Firm Making Disposition or to Whom
t----, Remains are Shipped, If Other than Above
M Address
. - -.
'.. Permiseton is hereby-ssiented to dispose al the humeri rea4ars-daseribed vs as indicate:113°
Date issued'CA\a 01Isa( Registrar of Vital Statistics c_____(-74
talenaturai
District Number c(sc-1 Place 1 6 ,...)-(-\. dC C
-_,
-
I I way that the remains of the decedent identified above were disposed ' %c••• . , ea will thkt permit on:
'ft:7i
.•'I Date cl'Disposition 8/2 41,2 0 1 8 Place of Disposition Pine View Cemetery Queensbury
oddln0
ge.5 Abenaki 11 -E 2
(section) . pot maybes) (grave number)
Name of Se n or Person in Charge cf Premses Connie Goedert
(please Ono
,T.....
----- Signature le 6( a4,c-Lc.ri Title Cemetery Superintendent
(over)
L. -1-1555 (02/2004) .