Breen, Judy ,. 1 /Iifs8
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last leer) Sex F
I �-
Date of Death Age If Veteran of U.S.Armed Forces,
(g-I4 I g W.S War or Dates
t# Place f eath ; Hospital, Institution or 0
City, r —
or Village •� h i Street Address / q s- wive ,)r Way
0: Manner of Death Iv 0Natural Cause fl Accident Q Homicide Suicide U twinined Cl Pending
Circumstances investigation
tu Medical Certifier Name Title
l U l ID Co r ortiy
. Address Zu `, o;,ae.e. S+, (rr v, 11L N y /L V-32.
Death rtificate Filed 1 District Number Register Niter
>' City, ow r Village t r,f x}r r) i
['Burial DatD(. ( 0? t Cemetery at /na Vi e�t)
❑Entombment I l
::E]Cremation Address aRK g : 6.0 of bur i r N L/ l Z f _
Removal Date . Place Removed
and/or and/or Held
' Hold Address
0 �' Date I Point of
ro 0 Transportation = I Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
Reinterment . r
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
Remains are Shipped, If Other than Above
Address - .
W.
Permission is h reb granted to dispose of the human rem s described above • cated.
Date Issued �� / aiRegistrar of Vital Statistics Uejt- )�]
J� signature)
District Number 5 ,67/ Place , °�'�' l _iKrt. Al J �-_2
1,, I certify that the remains (of the decedent identified above were disposed of in accordance with this permit on:
141 Date of Disposition Wit j/g Place of Disposition ,y U.. 0— 61-,
2' (address)
CA
iM (section) 'fiat number) i, (grave number)
ciName of Sexton or Pe son in Char of Premises G `,�p� r
//� ���� ( print)
Signature ILLG"� Title ( M�tt�,
(over)
DOH-1555 (02/2004)