Toarmino, Doris NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
1 . Name First Middle Last Sex
1�ris r' /O rmirio
Date of Death Age If Veteran of U.S.Armed Forces,
oCl j(jam I l r War or Dates '--
WPlace of Death , Hospital, Institution or
p'MCity,Town or Village 6 U.,a6 Fa. e) Street Address 'G (Li jt' &-j-- p-f—
aKner of Death OI Natural Cause ❑Accident Homicide 0 Suicide ❑Gnaeter�nint ❑Pending
ILI Circumstances Investigation
iij Medical Certifier Name n Title „
Addres%,2 1-iav( knot five F i t-' I`2-%-c) l
Certificate Filed i �� n n n # District Number G� Register NumbergZ,
C' ,Town or Villa e lQ Ylb L 1. .. 1
,: Burial Date i
U Cemetery o Cremato i ,I
❑Entombment ' j I v
Addres
`: ( Cremation CD uater c} .? C IP? r,00 Y i , N -il 1Zc`-f
Date Place Remove
Removal and/or Held
P"land/or
Address
Hold
Ul
0 Date [Point of
N❑Transportation 1 Shipment
0 by Common Destination
Carrier
<<`; Date I Cemetery Address
Q Disinterment
Reinterment
Date Cemetery Address
Permit Issued to Baker Funeral Home Registration Number
Name of Funeral Home
130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped, If Other than Above
2 Address - -.
CC
— Alb
P" Permission is hereby granted to dispose of the human remains d scribed ove as i dice ed.
Date Issued a!�1 Registrar of Vital Statistics �� '//
�� 1l.� ., ( 'nature) �.
District Number S./0' f Place '-C d%/
,' I certify that the remains of the decedent identified above wer disposed of in accordance ith this permit on:
UIDate of Disposition II/0 'If Place of Disposition P,,�.� Z..tur.�
W (address)
to
M (section) (lot of rber) (grave number)
aName of Sexton or Person in Charge of Pr mises /�rAr rv,�- S cti
Z (Pi se Pn t)
Signature Title • f12
(over)
DOH-1555 (02/2004)