Rawlings, Bobby 4 60
NEW YORK STATE DEPARTMENT OF HEALTH Buda, - Transit Permit
Vital Records Section
r.
Name First...-, Middle t Sex
cobbt ,Tern m e 11)Li/As m
Date of Death r Age If Veteran of U.S.Armed Forces, p A
7/ac1/aD i$ 1 (p_D 1 War or Dates
#e Pt.«: of Death r i Hos ' titution or /�
Town or Village Gke , �S 1 tree Address 1 J s+ HO- D e
Fa 4
0 'anner of Death�Natural Cause 0 Accident El Homicide Suicide 0 Undetermined ❑Pending
Circumstances Investigation
8 Medical Certifier Name TittleLi
Address IL M FiAtz,0,61 �'1.0
66 D b(Ld kP sr o f Filed 111
,_Deekth Certificate Filed //, i District Number Register Number
P' Town or Village LSI ki)S \ IS %01 ,
08uriai Date Cemetery or Crematory
['Entombment 13► 12 ►� Q� �� � Creir5c
Address
Cremation �j , .\I-e( (oc,, O.R-e t c bL-f 12 g 0 y
Date Place Removed
Z Removal and/or Held
2❑and/or Address
g Hold
O Date i Point ofles El Transportation Transportation l Shipment
a by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment ,
Date Cemetery Address
Permit Issued to Baker Funeral Home Registration N o ber
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
ILi
' Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued .713 i/ i ' ' Registrar of Vital Statistics L3 `
(signature)
District Number S f 0, Place G (sz S l\S i 1V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI 8
Date of Disposition i, /i$ Place of Disposition rmail.J l 7
W (addr )
fa
CC (section) (bl mber) <- (grave number)
0 Name of Sexton or Person in Charge Premises L 4,'. ' *
5 A (please int)
Signature Title -
(over)
DOH-1555 (02/2004)