Desaro, Dana f 7 go()
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
•
- c c-v \-e. An. cp F
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Date of Death Age ++ ,,0, If Veteran of U.S.Armed Forces,
s, i�� \ k 1/4-1 i War or Dates
P ce of Death I � '� � , Hospital, Institution or I L3 9 S.f. -TiI
Al City;Town or Village G U24 w ra i Street Address
ner of Death❑ILI Natural Cause 0 Accident El Homicide ElSuicide Undetermined Fending
O Circumstances --"--investigation
to Medical Certifier Name y�r,� Co Title .fro -" r
Address i s,,,i U Sfita 'LZ--} , 9, cat, L�-e 0 r9,, , Ni j I2 g-t(S
2Daa h Certificate Filedn /' District Number RegisterNumber
City, Town or Village lam( , t O f 5 k) 7 (.-i r3
Burial Date ?�. ; Cemetery Crematory
DEntombment S )1 `J iC W/ \I'40 C�`errIalc?-•
Address ,
-.11Cremation a)lk y)J' V.L` - (3. ��-,}()(L.2nQ5ur'L , V,`�' I 2
Date Place Removed
z Removal and/or Held
D and/or Address
Hold
0 Date Point of
a0 Transportation Shipment
ct by Common Destination
Carrier
' ElDisinterment Date ; Cemetery Address
;[ Reinterment Date I Cemetery Address
1 ,
i Permit Issued to Baker Funeral Home Registration N o ber
130
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
-, Remains are Shipped, If Other than Above
I Address
t!
tur
41" Permission is hereby granted to dispose of the human remains described above as indicated.
z
Date Issued 5) is 20 lc* Registrar of Vital Statistics CAA
signature) U
District Number S 60) Place C .s \\ S Vf
I certify that the remains of the
decedent identified above were disposed of in accordance with this permit on:
2 22.
14,1 Date of Disposition S :t I if Place of Disposition ," L. �. -tc.-.
(address)
W
co
Et ' ".
(section) nu ber) (grave number)
4 Name of Sexton or Pe on in Ch a of Premises -j, S-*.
,� ' ` (PI print)
Signature U Titleirk Mit
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(over)
DOH-1555 (02/2004)