Annette Jr., Charles • 0 # 13-)
VDRK STATE DEPARTMENT OF HEALTH
V;tai a'c5ords Section Burial - Transit Permit
...-::.....
71T—Irstie First . \Middle A Last. , Sex
.t (z,hOr le S L)or),)1-eon 1-1 opetie_ Tr: Azt
1 Date of pearl Age "rr I_ If Veteran of U.S.Armed Forces,
• I / War or Dates 1960 - 1 9 SO
Village jafreaS I) t Hospital, Institution or Li erbspe ce-t- S41.e.,e..t-
U urj i Street Address
E)eath 1E1 Natural Cause 0 Accxlent 0 Homicide 0 Suicide 0 Undetermined 0 Pending
1;-,t Circumstances kwestigation
Name Lj a Title Ilit'ain(\ Tedesco IYI_D
. Address
3 --Tror,90,--Ve e fr, C-I\ens Pa HS Y \isot
LYea#, - cate Filed ,-i I District Number Register Number
•_:- !-•,::Villa e iTe0S‘NAr
r 1 Date 1 Cemetery or Crematory .
ixne Q i eLA) C.-re-Poo-1-c rj
• Address
-: D.c_,. ::Jr 1 ei .)c,..\i-e-r Rock , 0.)e,ensborkA , IQ' t) 1-2, c.) 4
_ — Date Place Removed
and/or Held
,. ...._ ,
-J -• Address
Date Point of -
.. 2._ .
Shipment
Destination
—aisinterment Date Cemetery Address
i i
•
•.
: -- terment Date Cemetery Address
ile:n
. ' F-'arrait 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
Mil Address ,-- ..
,--:?---
'LA Permission is h bz granted to dispose of the human retneins bed aboves indicated.
I
:-: !
- Date issued 4? / Registrar of Vital Statisti ,
(signature)
District Number &0 Place 4 p/VotisZ
• i cerii4 that the remains of the decedent identified above we dis
of in accordance with this permit on:
: Late of Disposition i hi,III Place of Disposition emu e8,10-..
,
0
(section) . numbed (wave number)
Name oi Sexton or Person in Charge of['remises i ti.fittat7rintiS"As*
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.--ii P1•441110-
Signature A ./k--. Title •
(over)
I .-+4-1355 (02/2004)
•