Murray, Harold NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section .a! - Transit Permit
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Date of Death Age I If Veteran • . F. ces,
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j- Place • r eath ; Hospital, Institution or
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p Mann- of Death a Natural Cause .Accident Homicide 0 Suicide Undetermined ❑Pending
Circumstances Investigation
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Death icate Filed District Number # Register Number
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❑Burial Date /2-6
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❑Entombment Address
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Date i Place Removed
Z Removal and/or Held
M Hand/or ; Address
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O I Date , Point of
ei Q Transportation i Shipment
O by Common Destination
Carrier
[�Disinterment Date Cemetery Address
Date ! Cemete Address
Reinterment ! ry
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Permit Issued to I 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
II- Remains are Shipped, If Other than Above
2 Address -
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0' Permission is hereby ranted to dispose of the human r mains describe._. ;ve as indicated.
Date Issued V 1 l I-7 Registrar of Vital Statistics e�,_ /�„
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District NumberS(c) �) a Place 1 ,,L
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t- I certify that the remains of the decedent identified above were disposed of in ccordance with this permit on:
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ILI Date of Disposition II/Z31(7 Place of Disposition .(?i,� J r� -4,.,,
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0 Name of Sexton or Person in Charge of Premi es L%i r /44irr
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W Signature t Title • faMfi1f7A-
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DOH-1555 (02/2004)