Tracy, Robert -io 2_
:NEW YORK STATE DEPARTMENT OF!HEALTH *
Vita R,41ccrds Section Burial - Transit Permit
Middle Last Sex
... -toDex-1-- Da 1-414joes (YA
,v:;:i:, Date of Death 1 Age , , If Veteran of U.S.Armed ,
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Oeath
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,-"4-.-0 ,„virn or Village Gistiim Fafezi u t...,_ War or Dates
, Hospital, Institution or —
I Street Address GtorlA caJi(1 floS(0% totA
l't 'miner°t.Death f FrNatural Cause 0 Accklent 1:3 Homicide 0 Suicide 0 Undetermined 1011 Perbing
Circumstances Investigation
Me.aitai clertifier Name Title
PlAiaCLX SO1(5\a, ttiri Pluisi cLe.r.. Address 3c9t../ Rtui.
e 56(30(05,6pr,v91 N1 I 2.1qcsk
Lertiricate Filed r-, DistrictNum Register Number
• ..A1L n 4.: Village U-111A Rated6 0
.2L7zinfrd. I Date sz .21 t ' Cemetery or story . ' ,
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E:, '-'',1.kil,f2L1monti Address
Qoat-r. koot- (0 ueo.a3b:evI-10L/ rz_goq
, 1 Date Place Remo
and/or Held
Address
Date'' Point of ,
,x,“/.,,nt Shipment
Cl Destination
-J . Date Cemetery Address
,_,.. Date Cemetery Address
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tise to Registration Number
7vner Baker Funeral Home 01130
al Home
' Ati.,.1--,ipea- •
11 Lafayette St., Queensbury, NY 12804
NwAs cf Funeral Firm Making Disposition or to Whom
are Shipped, If Other than Above
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-:, tkddrese, -
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:'-•- Permission is hereby granted to dispose at the human remains described above as indicated.
,--...
issued Si Z.7/2_44) i Registrar of Vital Statistics
lAi--j1r4"-.' striatum)
District Number 560 t Place
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f;;,•4' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Zi
tali Date of Disposition f 14$Ils Place of Disposition et...0_1v 4rolor,-,
(address)
TA,
(section) . (lot lr,al) . (grave number)
Name at Sexton or Person in Charge of Premises i itt,,,,i,L. ,5„„„...
(please prOt)
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bf. /4rt
Title • /110A tki...
- Signature
.,_.—
(over)
1 <44-/556 (02/2004) • .