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Robbins, Lucky R # 7Zg NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle n/ (�Last Sex G/ i) lt So /C n) ORINS' /1161GI Date of Death i � 1- Age I If Veteran of U.S. Armed Forces, / ?J 7//7 I ,,3-- `? 1 i War or Dates 'tile _ }- Place of Death F_ Hospital, Institution or WCity, Town o Vilia Sn�;.,' , u�v.. c j'SFreet Address 7 c 1 c�a V,Z.t vie w !J Manner of Death Natural Cause Accident 0 Homicide El Suicide Undetermined `Pending Circumstances Investigation tu Medical Certifier Name Title qq� CI fit1i.6' IKl2 )C✓9 /l 17 Address N cco -L, 1 ,4-,- 4,0 %lam )242%v �/ Death Certificate Filed : District Dumber / Register'Number City. Town st illag- Rn U r/d G t,,,c Fin& I J ❑Burial Da e Cemetery , Crematory Q Entombment �'Z //7 .J V i&1-.) Address —_— ,�' Cremation C v 1«-,� Q iJ .IJ s U /U i Date { Place Removed G❑and/or ri Removal 1 and/or Held Address Hold CA i 0 Date Point of Uf©Transportation : i Shipment a by Common Destination Carrier Date i Cemetery Address ❑Disinterment i Ei Reinterment Date J Cemetery Address Permit Issued to uneral Home Registration Number Baker F Name of Funeral Home01130 Address 11 Lafayette St., Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom N Remains are Shipped, If Other than Above 2 Address V _. tr tti— t1. Permission is hereby granted to dispose of the human in described vs as indicated,, Date Issued 91 a€-l i 1 Registrar of Vital Statistics ` Q-. (signature) District Number LA S ak Place 6 3 '"13 1 1 Ire`K f! I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 14.1 Date of Disposition /0(Z 1 n Place of Disposition c� (L, 4 ,.ti 14.1 1 / (address) IX (section) { number /' ) (grave number) G Name of Sexton or Person in Charge of Pre ises { A, s PM" Z a (tie a print) w Signature Title MEMW (over) DOH-1555 (02/2004)