Morris 111 Willaim J. #W
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death ; Age . If Veteran of U.S. Armed Forces,
2�12 1202 0 13 r or Dates 1 q LO - �q�3
P e of Death Hospital, Institution or
(QW Town or Village C hnS (-a I LStreeTAddress C le n S Fo-I I S
Manner of Death5kNatural Cause �]Accident Homicide Suicide Undetermined Pending
_ Circumstances Investi ation
Uj Medical Certifier Name Title
G _
Address
ath Certificate Filed i District Number Register Number
C' Town or Village G has cz 11 S
❑Burial Date 2 ZO2.0 Cemetery or rem!!TD p Iry
❑Entombment Address -----''
Cremation
Date i Place Removed
"❑Removal I and/or Held
H and/or 1 Address
Hold
i
Date Point of
Transportation I Shipment
0 by Common Destination
Carrier
F�Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I 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
Address
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued IN ZC:D Registrar of Vital Statistics
U (!"cure) ---
District Number %Q _ Place G Irnfil �CA)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition oz- =zozGs Place of Disposition ��
(addry s)
W
N
M (section) (lot number) (grave number)
Name of Sexton or Pers n in Ch ge of Premises
(please pant)
Signature _ Title oReJ `�
(over)
DOH-1555 (02/2004)
Public Health Law Sec. 4145(2b) 0 13 3 4
Receipt '
Human remains of `. delivered on , 20
Pine View Cemetery Representing the funeral home named on buriat permit
Official Funeral Directors Reg.or License# —