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Breault, Shirley a 4' 4 3)0 NEW YORK STATE DEPARTMENT OF HEALTH • Burial Vital Records Section Name First Middle Last Sex 5`hhr1e,v I Finn L.-- F Date of Death Age i War i I If Veteran of U.S. ArmedForces I _ or Dates }-► Place - Reath ' Hospital, Institution or c N e ec-hamv I I l L.. l a fk L ‘ 5 City, ow or Village f(,r .1_jinn i Street Address a Manner o Death Natural a c ent Q Homicide ©Suicide 0 Undetermined u Pending '° ,. , Circumstances Investigation . tu Medical Certifier N. Title t 1 t la_ Y\ r 96 S 'l Ads . 11s,1 Core/ id( Ok- nburv, r►L( 12E-0 t.-( Death =rtificate Filed District Number Register Number City, ow'or Village Far 4- /9V1 ri ,�7-�- D Buria Date ` 1 g'Z0tg , Cemetery o remato 1 t12 v i c t t- Q Entombment Address f3 /�,1 t Cremation D l�Q..l�su __d ,) Q I J .QS2..Vvb u/�--.=� I IN`4 ..`2S v�-1 Date Place Removed Ej Removal ( and/or Held and/or { Address Hold Date Point of FA Lir'Transportation ' Shipment ca 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 t Remains are Shipped, If Other than Above Address fit t- Permission is hereby granted to dispose of the human rem s described abo a 'ndicated.• Date Issued in,c:er.,rpd Registrar of Vital Statistics (e -e,�/ (signature) District Number '2rj if Place I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 p /9 j If Place of Disposition ,,tL' `' #� Date of Disposition S ��„(address) LU IX (section) l (lot number) (grave number) aName of Sexton or Person in Charge of Premises / f±,,.vt /'� ( lease print) liti Signature _ (.�' / Title (n fAifi iU4, (over) DOH-1555 (02/2004)