Perrigo, Earle NEW YORK STATE DEPARTMENT OF HEALTH
•
1 !
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
- Earle Wayne Perrigo Male
A. Date of Death Age If Veteran of U.S. Armed Forces,
nia 02/03/2018 83 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined ri Pending
Circumstances Investigation
tu Medical Certifier Name Title
O Carrie Miron PA
Address
•
--7- i 319 Broadway,Fort Edward Town,New York 12828
a Death Certificate Filed District Number Register Number
• City, Town or Village Fort Edward 5755 6
OBurial Date Cemetery or Crematory
02/06/2018 Pine View Crematory
p ❑Entombment
Address
sk
-;>®Cremation Queensbury Town, New York
Date Place Removed
',V Removal and/or Held
1 and/or Address
Hold
O Date Point of
Q Transportation Shipment
by Common Destination
'„ Carrier
µ:DLL.
Q Disinterment Date Cemetery Address
v Date Cemetery Address
kin,Q Reinterment
s
�, Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
f Address
`t 11 Lafa e y tte St,Queensbury,New York 12804
M j Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
7 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2018 Registrar of Vital Statistics Aimee Atahoney(ECectronica1CySigned)
(signature)
District Number 5755 Place Fort Edward, New York
`gym I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
It
it Date of Disposition Z f l ilf Place of Disposition -P,.t kli 4,`,
(address)
(section) // (lot number) r (grave number)
Name of Sexton or Person in Charge of P emises 1 e, J i^.,Air
( ease print)
Signature Lam( Title / 14'114
(over)
DOH-1555 (02/2004)