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Chevalier, Kenneth I '1 1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First 'j Middle lehAart Last U i ., 5 (V1 nalia Date of Death i�ll "J Age If Veteran of U.S.Armed Forces, 1 ' ' 317/ LbIZ V+ War or Dates i (1.51 - i ci 3 1 Place Death Hospital, Institution or City, own or Village �()P pal S h u t� Street Address 3qiprriV that.) NI'1 ve_ Manne Death _4 Natural Cause 0 Ac dent 0 Homicide 0Suicide ❑Undetermined ❑Pending li Circumstances Investigation at Medical Certifier 10 Name sW-niv_ j Title I f h,ystCiC'-r Address 0-c t&MA\0 t Nq 1 2 Li De rtificate Filed ,, Dist'!Nu ber R umber C' Town r Village (31)ck t1 Nhu`if\._ e Eliluna1 Date 3 I (� G Cemetery or Crematory.--0, j` DEntombment -! �11 t- Address � OCremation Ci.1C. P.y �._)Ot 0uop fi lAhu r (4-) V. / -)`'( v Date Place-Removed ❑Removal I and/or Held and/or Address = Hold Date Point of 0 Transportation Shipment by Common Destination Carrier ©Disinterment Date Cemetery Address El Reintermen# 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 2 Remains are Shipped, If Other than Above Address CC lik 0. Permission is hereby granted to dispose of the human remains described a \vas indicate!. Date Issued 11 S 1 elO1 Registrar of Vital Statistics C rbJ'1—' (---- ---__„_., (signature) District NumbercLQc� Place ( O �,,_ ac C____ _&s2_2___‘\ ).s I certify that the remains of the decedent identified above w e disposed of in accor - ' this permit on: ' tw Date of Disposition 3 I i4JW € Place of Disposition 21 1�• Qum. (addrrss) 1 (ror number) (grave number) 0 Name of Se ton or Person in Charge of Premises l.O&on14) L, 1�0abt 1 Signature Pt 11� da.►'� TitleG ' f ' 4 (over) DOH-1555 (02/2004)