McCall, Fawn i- . # (fol
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middlew Middle n Last Sex
J` _fi
p" ` C. l f
Date of Death Age If Veteran of U.S. Armed Forces, II��1
Sig U \ \ c S I War or Dates idYd"
Place of Death Hospital, Institution or
City ��o �Fi or Village m�')\(2..1 ,U Street Address CO2 fiat Y l SO,r•i ' UC_ �.c,Q�
Man�terot1 Bath Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ui Circumstances Investigation
ILI Medical Certifier Name Title
CI \ ab., ) STOUP ,jth t-S / 1 )
Address Pgitig_
Death Certificate Filed District Number Z I / Register Number
City or Village trio(p AA ) ! - Z9
❑Burial Date Cemetery o atory�
Si el POO IYYU_ Vte(A)
❑Entombment Address
"Cremation (' U f ' L 06) (�()PQ1)C l PN' (2 oLi
Date Place Removed
g❑Removal and/or Held
and/or Address
Hold
Date Point of
go Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
->? ❑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
aRemains are Shipped, If Other than Above
Address - ••
M
a. Permission is hereb granted to dispose of the human n aunt+8iscribed a indicated.
^
Date Issued ol( )6 f Registrar of Vital Statistics
71,,,10,/(
(signature)
District Number `i D_ Place 16 0 4 0 1 U rQ at,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /z3 (ig Place of Disposition PAL, j ` t. -
(address)
U)
(section) Al (lot number) (grave number)
£V Name of Sexton or Person in Charge of Premises ti -,,,i i
(pee pant)
Signature �^ Title el giU2
(over)
DOH-1555 (02/2004)