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Poleto, Mary 1RK STATE DEPARTMENT OF HEALTH T Vital Records Section Burial - Transit Permit Name First Middle Last Sex Date of Death Age If Veteran of U.S. Armed Forces, -T I2 FT I ( Sc ' War or Dates 1— Pl.ce of Death I,, ospi institution or S el Town or Village C1 ith•S FA I I S i dress C J-�/h.f Fills l l nner of Death t��'Natural Cause Accident Homicide Suicide (�undetermined Pending W �� ❑ ❑ ❑ `"'Circumstances ❑Investigation g uj Medical Certifier Name Title .}.43 ' (MD C 0./0")(")C 4.„: Address r h Certificate Filed 5District Number Registerplumbs; Town or Village S � I+S I j a li nai 1 Date kin Cemetery ematory ,/ 7( 2' 1/7 P1 C V i ,'c` ©Entombment i Address.'` � ^ J "91Cremation I Q vkblti, t - l QSQ i " j Date [ Place Removed U� f❑Removal 4 and/or Held ... and/or Address Hold imi Date Point of cii❑Transportation Shipment G by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Rein#erment Date 1 Cemetery Address i i Permit Issued to Baker Funeral Home Registration Number 130 Name of Funeral Home Address 11 Lafayette St., Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom h Remains are Shipped, If Other than Above 2 Address . 1 Ilk 41" Permission is hf(di7 by ranted to dispose of the Kumar smains ibed ove as in. f .. Date Issued � Registrar of Vital Statistics al signature) District Number Place I certify that the remains of the decedent identified above were disposed of in a cordan a with this permit on: ILI Date of Disposition / //7 Place of Disposition y7 e u,,- c f€ Z by W (address) / 0 IC (section) I //(lot number) (grave number) QName of Sexton or Jçchar9e of Premises LA->l i a-� C.-�/yt�c `o z (please print) Ut Signature Title C le-W aciki (over) DOH-1555 (02/2004)