Cutter, Darlene NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Muria! - Transit Permit
Name Fir t Middle Last Sex
Date of De th Age ii tf Veteran of U.S.Armed Forces,
1' ) t 20 (% �2 { War or Dates
Plac of eath � I Hospital, Institution or �J
t i Cit( Town r Village ( )Ue 'v-Ns 1 Street Address i i1,41( -p i-v
B Manne Death Natural Cause ❑Accik�ht D Homicide 0Suicide Q Undete med Pending
W Circumstances Investigation
uj Medical Certifier Name g D6 e r-1- ^n. a i U TitleCI M 0
Address �rC�C)��1 �'�) ,..„ �1�-�-Y�O, lV Li 1 2g��
Deat -icate Filed C•�J i District Number I Register Number
City atrVillage 0 c13uY I . 5�o 5,1 i I `oL
!l, uriai I 11 Date ; Cemetery r Cremata
i 0 �S ry �-. I hc,n ,.,
1
i. �E;�Yombment Address' �� 20\
`_°:[Cremation 1- � VUwt'v2- Cot=i COe.�nS�uburs !Vof n_go q
Date Place Removed
Z Removal 1 and/or Held
RI—and/or Address
GOrioid
O ( Date Point of -
85 0 Transportation f 1 Shipment
cti by Common Destination
Carrier
Date i Cemetery Address
}Disinterment I i
t t` ein-rerment
i Date I CemeteryAddress
r.
PermitIssued to ` Registration Number
I Name of Funeral Home Baker Funeral Home 01130
Addi e.ss
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1--I Remains are Shipped, If Other than Above
• Address --
CC
4' Ps nission is hereby granted to dispose of the human remains described above as indicated.
tDate issued 1 k-a,-a,()t Registrar of Vital Statistics --4-La-1 , t k,J\ ?
(signature)
District Number rj(r 1 Place Q J e e rts b J
AI
I cer�•ty that the remains of the decedent identified above wera isposed of in accordance with is permit on:
Zi
I�
ili
f Date of Disposition = Place of Disposition 54. A)F,/1r n 50.D .1 6-1PC: if b. ✓ i
(addrejs)
2
(section) ] of n ber) (grave number)
Name of Sexton or erson in Charge of Premises t (pe
ZI / (please print)
'1 Signature �C / _ Title -
(over)
DOH-t 555 (02/2004)