Proctor, Marlys itJ1L
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Mar 1 S Middle A�� Last p` � Sex I
y
Date of Death 2151\ZO $ Age is l2 If Veteran of U.S.Armed Forces,
Dates
.- of Death
cArss
or � .own or Village G - -L4
;. V anner of Dea IN Natural Cause ❑Accident 0 Homicide 0 Suicide 0 Undetermined ❑Pending
ilii Circumstances Investigation
iii Medical Certifier Name Title
C �..�mc'a ( cx �lv
Address
32--7- ?)coad Weth fo4- eck,ub-a--) No IM-S--
Certificate Filed District Number Register Number
ity,Town or Village �S A- �n-' ` _
Burial Date 2 '26 0? Cemetery orc remato ) pi c V i 2 u
QEntombment Address
Cremation Q ULA. (Zct ,, auws wt :.1 1. w-'1 12-lfJL
Date Place Removed
*ri❑Removal and/or Held
andld/or Address
CO
Ho
Date Point of
0 Transportation Shipment
is by Common Destination
Carrier
0 Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
i _
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
Remains are Shipped, If Other than Above
Address ..
5
Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued 2..t i z( 'Bo/$ Registrar of Vital Statistics cA h 4.
(signatures)
District Number 56o y Place ,u_,,,,S U \\s G
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition f;,V.." 4.-.4..-
' (address)
ILI
In Z/byIli
(section) Iot number) (grave number)
ci Name of Sexton or Person in Charge of Prem' es " ( nt,S 4t
/�, (>�� )
Signature �-�( Title ltmii1U -
(over)
DOH-1555 (02/2004)