Woll, Helen ( . i
" 63
NEW YORK STATE DEPARTMENT OF HEALTH sa
Vital Records Section Burial - Transit Per �t
Name Firsti/
��n Middles Last /w`O // hex
Date of Death Age (If Veferan of U.S. Armed Forces, /
/�>//l� g XZ ates NO
Place of Death �` / ospi stitution or" // /
4,0 Town or Village e le ,r 1�Gc-fJC Street Address b`�e/(s- ra, (r AceJi�./1
. =nner of Death(''Natural Cause Accident Homicide 0 Suicide Undetermined 0 Pending
W. f�' Circumstances Investigation
W Medical Certifier Name Title r
0 �I rf < rr4i/Gt )j
Address (� i
/� J'7—. �t ^Tl F 1 it/9
tD Cert ficate Filed /' / s District Number ` R is Nu ber
own or Village 1/e/iJ t"a..(is �l 1.
❑Burial Date 7' /2O77 Cemete o o
[]Entombment Address �1[ /F.u� e/nalty
Address L
= remation NliC�i�K4' �Cc,G� AsLileAthiILILIz ev) 4- _ /Zipy
Date Place Removedj
n Removal and/or Held
C3 and/or Address
Hold
O Date Point of
05 0 Transportation Shipment
ct by Common Destination
Carrier
0 Disinterment Date Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Baker Funeral Home Registration Number 01130
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IX
la
IL Permission is hereby granted to dispose of the hums remai a descr ed above as ' dic ed.
Date Issued Registrar of Vital Statistics eL G��—�,.
2t(j signs re)
District Number de Place Cr_i4
I certify that the remains of the decedent identified above were disposed of in acco ance with this permit on:
Z
ILI Date of Disposition _ _ Place of Disposition .PnA,, errrodf or' ...
lid (address)
Cr (section) //(tot number. (grave number)
taName of Sexton or Person in Charge of Premises (r . tt
z ,a (pi se print)
4Lt' Signature i. ( Title IIKP)Oi2
(over)
DOH-1555 (02/2004)