Diamantis, Rene c ; 1435
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
Name First Re t,z_ Middle _ Last alcAry S Sex F
Date of Death Age If Veteran of U.S.Armed Forces, _
D1 17_018 S4 War or Dates
Place Death , Hos itall institution or
tj Ci Tow n r Village Qv`c2. �&a'JU treat Addr`ess'-°, 2. � l� Dr .
Manner of Deatl?r Natural Cause [�Accident Homicide Suicide Undetermined a Pending
til 11��— Circumstances Investigation
u F Medical Certifier Name CI 0` , 1 ir C.L Title M
Address `I_o t-uv \-)•,, G Lam__FcLitiai Ni-1 12.'RO
Death Certificate Filed District Number Register Number
City own r Vitlavc e Q ' � '( I 5.(s_s
❑Burial Date o1 '`u1zola ; Cemetery r Crematory •
p1ne.. \
❑Entombment
.atAddress p A
remation �1��- f� ,} L--)( 1.4'Vnb�tt�-Li �)`�!• 12��1
Date Place Removed
Z Removal and/or Held
2I-1
and/or Address
en,
Hold
0 Date Point of
N❑Transportation Shipment
0 by Common Destination
Carrier
Date i Cemetery Address F
Q Disinterment 1
El Reinterment Date I Cemetery Address
Permit Issued to Baker Funeral Home Registration Number
30
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address -'
IX
#tt-- �
Permission is hereby granted to dispose of the human re •' s de r b s indicated.
Date Issued I -C\--p t� Registrar of Vital Statiatirs_-_- � ) ac
< (s►9
District Number (..o5'7 Place
t- I certify that the remains of the decedent identified above re disposed of in acc ce ' this permit on:
Z
La Date of Disposition f /2//,/,/i9 Place of Disposition i Z)6 v;e,�)
W t� (address)
t
CC (section) AA (lot number (grave number)
QName of Sexton or e o incharge of Premises �) k 1, -A c In -e
(please print)
W Signature �_ Title • e-r'e-m /--
(over)
DOH-1555 (02/2004)