Merrithew, Celia I 4 Il
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
rName First Middle Last Sex r.
... ' Lto, `�Of 'MUT C A f�
Date of DeathC Age If Veteran of U.S.Armed Forces,
I �o� �� LQ2 War or Dates —
-_ of Death , Hospital, Institution or
,,- City. own or Village 6 J0.11,1 Street Address Jo �tC r[)�C S ram+
ner of Death Natural Cause 0 Accident []Homicide 0 Suicide Q Undetermined 0 Pending
a Circumstances investigation
c Medical Certifier Certifier Name ` � ea'a Title i AD
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Address
'.3� (6►'ir c c kicQe (( Eb(-A - (rd ( N`i 12 2�'
-1 f Certificate Filed = District Nutkbdr � 01 Number
Town or Village S Fujiii l �-U'"(
- •Burial `` h 31 1 Cemetery . r -: story'
VLQ. V
D Entor brnent Addr SS
Crem sation t ( ni(C i riCtkdi TV-0_42.41(i_itN
'`.1 I 2 Vb LADate lace Removed
e ovai l nd/or Held
ct--" arid/or I Address
Ilt Hold
Date Point of •
t T .
a s ortabon Shipment
=' 13y Common Destination
Carrysr
�g1trment Date Cemetery Address
Date Cemetery Address
7 al �::;rment
Pei Ott issued to Baker Funeral Home istration Number 03
Na3 Funeral Home
11 Lafayette St., Queensbury, NY 12804
N r1 ca Funeral Firm Making Disposition or to Whom
I'>c : riz,are Shipped, If Other than Above
I. A.d _ - -
Fa3
.; Parrillan is h by ranted to dispose of the hums remains desert as i
x to issued ' S7 Registrar of Vital Statistics Ili - a�
District Number ` - 01 Place T i ���� . j/ ('
i ,x gat the remains of the decedent identified above ,ere disposed of in accordance this permit on:
Ig Date of Disposition III�5'1 f Place of Disposition 40,, r '.for,
( e
c (section) ( (grave number)
a Name of Sexton or Person in Charge of ppremises
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2 ' ZIr* Ping
Signature Title la-nlvi��
(over)
DOH-1555 (02/2004)