Obermayer, Elizabeth 1a.I)
NEW YORK STATE DEPARTMENT OF HEALTH 1 Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
LI 2. ETA}' aS 4N `' C & M a 76r 1=g-n 19 Lc"-
' Date of Death Age If Veteran of U.S.Armed Forces,
3//0 I
/�' 611 War or Dates ,,J /P-
Place h or
City To Village Q v�Zd.0S g tJ12 Street Addrestton
Manner of Death'Natural Cause [] cident Homicide El Suicide Undetermined Pending
iii Circumstances Investigation
Medical Certifier Name Title
Ci Mlr Sct_n i)ky5:G,{n
Address V ('� - 12 ko
P C�vE�:���Inv `�Iv
De, I ,rtificate Filed ) District Number I Register Number
City, ow a Village Q-Uee�)s(iun�1j S L. 1_ 3 u,
❑Burial Date 3 J Cemetery or Crematory.
❑Entombment i i 1 J ?\V\J V t.e,w .efr
ialb/
Addres
OCremation (UC,K,y S2-oc d 0 i,�AlA hUY`t N y 12-"V
Date 14 Place Removed J
❑Removal and/or Held
and/or Address
Hold
Date Point of
1E1 Transportation Shipment
a by Common Destination
Carrier
"` Date Cemetery Address
El Disinterment0
Reinterment Date Cemetery Address
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
2 Remains are Shipped, If Other than Above
Address L ••
CC
ILI
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3 --\ - 0 17 Registrar of Vital Statistics 47 QAA -c&A c Q c.,, ..,
(signature)
District Number Ju,�I Place DO e eo s b U RI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 31 III lit Place of Disposition f?,,,i j. , .
(address)
ILI
(section) A (lot number) r (grave number)
II Name of Sexton or Person in Charge f Premises ll/�N, J'—ti
it
dse print)
Mall Signature Title &mit PP-
(over)
DOH-1555 (02/2004)