Burch, Lloyd NEW YORK STATE DEPARTMENT OF HEALTH `al a Transit Permit
Vital Records Section
-' Name First Middle 11 Last t.,� Sex t.1 1
1.1 U\-,10 rl
Date of Death 1 Age l If Vetere U.S.Arm Forces, f q C9y r G�O
�� l 8 1 i �5 War or D
i=. Place of Death ; ospi Institution or n S Rut s
Gip Town or Village G�Q,("1S F0. ,D' ' tree ddross l� f- -�
0 Manner of Deat natural Cause []Accident Homicide Suicide
Q Undetermined 71 Pending
Circumstances Investigation
4
it Medical Certifier NameL3r Title M D
Address &AA 10 j 1 Q uas , 12AU�
' Death Certificate Filed ►��r 0. .A. District Number ` s Register Number
,, )Town or Village i ' I `
10Suriai 1 Date s Z i 12o i s Cemetery . remeto �ln,e_Vl e
DEntombment` Address (� ' /� o /�- RA cl
1.:.YI/_lCrer;f ation 1 t..]+�M�- u.. `) AAD LA �4 ► �" ' 1 zpo
�` I Date t Place Removed
{
:naval , and/or Held
'
ruoold or Address
i
H
O, ( Date Point of
u Transportation 1 I Shipment
3 .y common I Destination
i Farmer
= Date i Cemetery Address
I LI Disinterment
i - Date 4 Cemetery Address
€tee:riter!maflt j i ✓
•
-., Permit Issued to i Registration Number
Nam's of Funeral Home Baker Funeral Home i 01130
I Add Les
11 Lafayette St., Q.ueensbury, NY 12804
Nan-le of Funeral Firm Making Disposition or to Whom
II Rec-.e s are Shipped, If Other than Above
-Z: Address _ ..
4# Permission is herein vented to dispose of the human remains described above as indicated.
Date issued 43 c 231 214; Registrar of Vital Statistics w Ck.44-1,U..
(signatu )
District Number 5 60 ) Place 6 C ,v�S `\s) 6,1 y
l:al I c a iiiv .that the remains of the decedent identified above were disposed of in accordance with this permit on:
gi
L-` i Date o Dispositong-? ..l�r Place of Disposition Piht,_ U co C,Rdatc4crY
21 (address)
I {section) (lot number) (grave number)
01
call Name of Sexton or Person in Charge of Premises deAAn.c.Y JtuiredS
,vi ' ` (please print)
'141 Sig_Fature A . - Title Llimai-tr
r
(over)
DOH-1555 (02/2004)