Edwards, Jarrod NEW PORK STATE DEPARTMENT OF HEALTH Urea! - Transit hermit
Vital Records Section
EH:- Name First—y Middle Last Ed upa.ci7, j Sex m
Date of Death Age ! If Veteran of U.S.Armed Forces,
} OS\N \2D\� 32
' War or Dates
1 Place of Death Hos itai, Institution or h(� v 2-11W City, own or Village Irmo(-e Street Address 10/3 Harr k S on live—
W Mann- _ 'eath 0 Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
0 N)cL lies V ,)hn Ccr 0n32...1
} Address
`-I O Plc, a Slt-cr S-i-, ?-Q spa. INN12-0ZU
• Death Certificate Filed i District Number I Register Number
City qov or Village or
p u I �� y S(D - 1 Si
. ; Burial Date Q U 1 iiCemet.ery Crematory i
Q Entombment U. I I n 11 }
Address
OCremation ► O un ilre.r ue o bu r N ''•-r /2 cc)y'
Date I Place Removed r
Removal ! and/or Held
2I-1
and/or Address
U) Hold
0 I Date ( Point of
83D_`t Transportation ( Shipment
ci by Common Destination
Carrier
� Date i Cemetery Address
1 0 Disinterment
. 3 E ein errr�c�t I Date ( Cemetery Address
I� -
'I Peranit Issued to Registration Number
Name of Funeral Home Baker Funeral Home I 01130
. 1 Add;ess
i 11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
II--I Remains are Shipped, If Other than Above
-21 Address _
Pe;-rnission is hereby granted to dispose of the human remains described above as indicated.
•! Date issued ro/y/! $ Registrar of Vital Statistics 4t-e A- 4/ �24 -L-
1
(signature)
E. District Number y 5lo a. Place 770 A.J l of AO tit &�
t -_
1 i certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zi
ILI Date of Disposition 6/6/-201 8 Place of Disposition Pine View Cemetery Queensbury
gLA
(address)
fii' Erie 4-H 1
M( (section) (lot number)
(grave number)
etName of Se on or Person in Charge of Premises Connie Goedert
(please print)
W. Signature 6-1c/U..� (Z' -e` _ Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)