Winslow, Robert 4 31,.., • 4, It
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
1.: .:. Name Firs; Middle Last Sex
•V:i",.. Date of Death Age, / I If Veteran of U.S.Armed Forces,
l' /- -a - a07 ? (0 GO [ War or Dates
1... Place of Death i Hospital, Institution or
— , 1
Z City. Town or VillageSGrc,ft .k. \/' r t'n i Street Address 6a),-C._.1-43,0 A. H POS . / i4 .
11.I
,C3 Manner of Death
1710tOatural Cause 0 Acci nt 0 Homicide El Suicide rj`U.ndetermined Pending
14.1 Circumstances ''—ri'Investigation
(,)
Medical Certifier Name i\ i Title
{ ..
Address 5-0 sbc 00_,0 9-,i yoke j_6(i) k)Li I z 1 s.T
• ath Certificate Filed (-\\ick.\--91, 4/1 oce ; District Number
I Register Number
i
(.#a
e'.. Ci . Town or Village `-'" 125-11 I
Date Cemetery cx Crematory
:,.:.• urial --/, Fi'iNt_ We k.....S C r te vytc-1-0 i^ k..tt
. DEntombment Addr,,,s
Cremation 0 jc \(_e v, coo_ 0 0,te v)5 by i-1/41 Ai -\1 • / ? PC Li
• Date Place Removed
3 ni Removal and/or Held
and/or I Address
rz Hold
Ei)
0 —I Date Point of
E Transportation I Shipment
by Common Destination
I Carrier
Date Cemetery Address
ILI Disinterment
i;•:;: , ,
I Date I Cemetery Address
_-....1E Reinterment
Permit Issued to I Registration Number
Name of Funeral Home Baker Funeral Home
01130
. I Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1-- Remains are Shipped, If Other than Above
Mr-A-ddress _
Er
—
C4i Permission is h re -.wanted to dispose of the human reme:..- es ibed_phtove cs indicated.
Date issued Registrar of Vital Statistics , 1- -41/L ,,a,
. (signature)
! District Number ill 50/ Place
SA1M-NOCA- ?0--1A.;t4 )
_....,_
1,..i I cercify ihat the remains of the decedent identified above were disposed of in accordance with this permit on:
Mt
11.11 Date of Disposition i/ID !if Place of Disposition ed.' a-4_
gh (address)
ft (section) A(lot number) r, (grave number)
01
ol Name of Sexton or Person in Charge of P ises /A 42.- 3 -_pf I
J=; (pi se print)
,, -C if tF Mt}Vt.
Signature ____ _ Title •
_ _......_
(over)
DOH-1555 (02/2004)