Bolton, Malcolm I 1 It %3°
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
1 Name First H cacs,:\prl . Middle T, Last 60\-Von Sex H
A: Date of Death 1 1 Age ci5 If Veteran of U.S.Armed Forces, 1 q 43_i q L4 to
, .....
‘ 1%S120‘t War or Dates
.,...
' Place c "alb QUSSLC) V3C-l X i i H " ' •
City own ir Village
mantle ' DeedhIllt Natural Cause 0 Accident OStreeHomt'Address• SulnciodreICIMPundsterrnined(1 rlePancling‘
`—`Circumstances `—`Investigation
Medical Certifier Name S- Title
-jt A
...: . Address 7
I b / C
le-4J Qo 6v--Ais g
...-: Deathate Filed r, irig-i,f Number
-':V-
I'-': C'ts, T-oviOor Village L-Nu-g-Q-nb(-1-1\1 Co-
: ial Date ur Cemetery Crematory
.ress
Date Place Removed
,./ f
Removal and/or Held 7
and/or Address
-0 Hold
4". Date Point of
in 0 Transportation Shipment
by Common Destination
: Carrier
,,. ,, Cemetery Address
u Disinterment Date
K.'t
..'..
Li T*1Reintennerrt Date I Cemetery Address
I
Permit Issued to Registration Number
;.,..i 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
---4 Address ----- -
17.:0
Permission is hereby granted to dispose of the human% described atm as indicated.
.-- Date Issued I 0-1 lof-E;01%egistnar of Vital Statistics
(signature)
District Number c."(..g -e•-') Mace 1 C.)--
-.." I certify that the remains of the decedent identified above were disposed of in accor ' this permit on:
tI Date of Disposition ID I ) I(f Place of Disposition gut)
2 (address)
1
et-i-- (section) . got number) „ C (grave number)
Name of Sexton or Person in Charge of Premises
(please pring
Signature A k Title • lizcintiM
(over)
DOH-1555(02(2004)