Bonen, Nicole . . t
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section . Burial - Transit Permit
• Name First . . Middle Sex r
M l CO(.0 * LtoitkAn
?: Date of Death I i Age ,- . If Veteran of U.S.Armed Forces,
•
---:-. , i )5 1 ‘ 1 cl - ' War or Dates
street A (-1
1 t al' i_ LO‘ ildi0 206.0L
(ei, Ail;',nne eath EaNatural Cause 0 Accident oil-ITO& ri Suicide L jr-1 Undetermined n Pending
Circumstances 4"-a investigation
Cattier Name on Title tt
el 1 i
EZ r k Sl-be 1(1SX !Ran ti re-ad--z-'.riji ?ilk's 1 ci
. Address
(62— C ait V-- S-V_, 6/ (g-iu0 -d-CC0 i N\-1 12,ScY 1
Death -rtificate Filed ,r) I District Number Register Number
O. '37 Village Dz) 17.5Y) 6 650 10
......._ •_ __
1 LIR'LTIE! I Date
! :kr / 1 Y Cemetery or Crematory
Addy Ti vu u t0 tA, cLeAln evizYi
-,
(5 Nfoc4AK go4-( CP UPPAe419b • A) /are)1
, 1 Date Place Removed lit' /and/or Held
Address
Date Point of
Shipment
' - - - Destination
—_ ,0 Date Cemetery Address
__.L..',--•='..,F1-11 it
Date Cemetery Address
Registration Number
Baker Funeral Home 01130
., At:,' • _t_ -
ii Lafayette St., Queensbury, NY 12804
.Firm Making Disposition or to Whom
if Other than Above
...:-
_-
'''-'• E.---'emiesion is hereby granted to dispose of the human remains described above es indicated.
-..,
C)ate issued ciil I-11151- Registrar of Vital Statistics RartIN- & Qsst-i\.
(sienature)
" L--,,istrict NLimber to c- 0 Place r---. 30Vvoir-N
.: . t 'certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Dispositione-k)45( Place of Disposition t i'•4c., Y;‘..0, Crt#P-IcrY
rz - (address)
‘..'&
W'r
MI' (section) . (lot number) (grave number)
*i
Air Name of Sexton or Person in Charge of Premises Trziktr4-0)' Sqjj:tc,S
(please ping
al,
• • Signaturee Title Cit44q1cir
(over)
L314-1555 (02/2004)