Shaw, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH But`I�1 � Transit Permitf•'Vital Records Section i
Name First Middle Last Sex
I_ckwv-ex\c e M\-e_v\ SV\c-L•3 'M
Date of Death A e If Veteran of U.S.Armed Forces,
/ - a Ca - 2 / War or Dates _
P ce ea#h Hospital, Institution or G e t nsbv v•Y , !�%- / d (Y o Lf
la Q u��.b L) '/ Street Address 5I Eu e fr r e(-) l-n . ' 3 a
W, Manner of Death#)Natural Cause El Accident Homicide El suicide [�Ui etermined 0 Pending
}"� Circumstances Investigation
W Medical Certifier Name Title ita (1 t(1 s h2( Y1O�--- rhys i cczr i
Address /02_ Pa/L S1-,) QAZ/ CLL , AH /280/
Death h •ccate Filed� ` District Number rr Register Number
ln• L:) Uee- 5bur ( 5k J1 tlrL
❑8uriat Date Cemetery or Crem ory
DEntombment Addr s _ 1
uprema#on U?QC).V., e18- jc oi , G..! e e v)`)k0 U v LI - A--) `-i • ')- p L/
Date I Place Removed
Z Removal I and/or Held
2and/or❑ Address
Hold
C' Date Point of
N[3 Transportation Shipment
3 by Common Destination
Carrier
0 Disinterment Date Cemetery Address
';[ Reinterment Date Cemetery Address
Permit Issued to Baker Funeral Home Registration Number
Name of Funeral Home 0
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than.Above
X Address
CC
ttt
--0' Permission is hereby granted to dispose of the hurnan remains described above as indicated.
Date Issued l a-3.i -ao i I Registrar of Vital Statistics - R a4 t --t,`Le
(signature)
District Number 5\,.S 1 Place 0 0 _c, it c b‘,,
),,j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition J yz i'? Place of Disposition Pjhcevi Irv/- r
t33 (a ess)
t%3
tr (section) ` ( number) (grave number)
Name of Sexton o in Charge of Premises 3 - /, .i 69 :. �k
z
(please print)
t1Signature Al� '`'-- ,-,e_.
g Title • �
(over)
DOI-l.1555 (02/2004)