Volk, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burials Transit Permit
•>' Name First Middle k.Etpt Sex
1_.)on or 1t o L.iC Fe/Aft v/
Date of Death / / Age 1 If Veteran of U.S.Armed Forces,/
$`/8'I 1 k R/ War or D=W A)/I$
Ptace th "to'
i Hospital nstitutio i ('�
5 City, o r Village a b- -U I Street Address Mil if e (oa rn J,i "P11-61
0 Manner of Death 1 Natural Cause 0Accident 0 Homicide 0 Suicide 0 Undetermined n Pending
tki �l Circumstances Investigation
gi Medical Certifier Name TitleL)
/ �-�, >��.J � ,� .
. Address y� �( ,{ ` r,
Joa/ ( 9 t&--' i & to 6Y. t-S e U /" l Z o y
Deady cats Filed District N r R e Number
_' City, own' Village /�o IF: "' --
❑Burial Date Cem, tery o
c:/ /cT !"t,r r.-s' r i ty
❑Entombment Address ,�1
gCremation CZ u 6/4,b"YL rz au n)S eg ()7
Date ` ; Place Removed ,,,A);/
Zo Removal and/or Held
l=P and/or Address
Hold
1,11
a T Date I Point of
cils Q Transportation Shipment
a by Common Destination
Carrier
... ❑Disinterment Date Cemetery Address
°_ Reinterment Date I Cemetery Address
Permit Issued to i Baker Funeral Home Registration Number 130
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
ILI
12' Permission is hereby granted to dispose of the human remai closed b® as indicated.
-. Date Issued 03 000/8 Registrar of Vital Statistics lall G�!,t
(s►9 m)
District Number L/SI4 D Place /Y')QQRt( �. /3/
fni. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
kW Date of Disposition the lit Place of Disposition ?,4/(1--/
C,,,C�
(address)
CO
(section) (lot number)„,
_ (grave number)
Name of Sexton or Person in Charge Premises (i""lip J
(please Print)
U Signature G Title • Cf1t17)"'
(over)
DOH-1555 (02./2004)