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Warington, Veronica # S38 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First ,r��n i C . Middle A l Max Le._ t Way n -j sex Date of Death Age If Veteran of U.S.Armed Forces, i �t 8 LpO War or Dates Z Place each ; Hos (tutton or rye RA Z City, or Village ©'t-ALQ, )°wu.i ' treat Addres S/. KA CLOS_ , 0 Manner of Deatt1Natura1 Cause °Accident , Homicide 0 Suicide °Undetermined °Pending LU Circumstances Investigation w Medical Certifier Name Title ir, CI (AJ 1114 vh ! SCv •M Address l S �((i d j f 2T 3 rvzi -Fe. Ce��-cam. Death icate Filed okk( Q(�L 7 District Number I Register Number C To or Village �'{ I 54 5`1��_ ::°Burial Date -4-\ I ,25-3 i g I Cemetery Crematory ) i-VW- v ilZ vJ DEntclubment Address t � " � • Cremation ks,r U .) Q L 12..tt &��u..L-L j , P`-1 12 ()LI Date Place Removed °Removal I and/or Held and/or Address Hold 8 Date I Point of ei 0 Transportation I Shipment 0 by Common Destination Carrier Disinterment Date Cemetery Address 0 Renterment Date I 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 II Remains are Shipped, If Other than Above a Address t 4 Permission is hereby granted to dispose of the human remains described above as indicated, 3:. Date Issued 1 -a- a o 17 Registrar of Vital Statistics -- 4A ' k (signature) District Number s1r57 Place (" v ecil S h V 1 til I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: LU Date of Disposition 1 134i 4 Place of Disposition '1e�'f' Linr•rt,a.• a, - (address) L3 0 (section) number) (grave number) Name of Sexton or Person in Charge of Premises X.17;,;,* 3f.pol1 Z ( Pint) Eft Signature 0 Title i (over) DOH-1555 (02/2004)