McManahan, Kelley / g
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ke 1 l-e Chars V CMg.)AA.
Date of Death Age I If Veteran of U.S. Armed Forces,
11.E l30 I ao 1 P-- La C) War or Dates /9 767— /Q 79
t. P .ce of Death I Hos ital, Institution or
Z own or Village G lQ..n p S Fc Street Address - L H el(..Q.Y\ S-i- #Z
tii T anner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
'� Circumstances Investigation
Q THY Medical Certifier Name Title
fCvm .e v Coro ruz.,(
Address I Li O _.1/4, v.4- 9 La Le- becxy_ ,(y",'. I Z5- Lc
D Certificate Filed i District Number Register Num r
City, own or Village C ie.n S s i � �
Burial Date i Cemetery em ory , /
❑Entombment Address II ` ) v t cremation Q u-(-e rI c l0 Q L , 1) "/ I Z& 0
Date Place Removed
g El Removal and/or Held
G and/or I Address
= Hold I
C) ( Date j Point of
65 Ej Transportation i Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
1
Permit Issued to I Registration Number
Name of Funeral Home Baker Funeral Home I 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1.— Remains are Shipped, If Other than Above
Address - .
CC
12- Permission is hereby granted to dispose of the human remains-descr ed above as` i ated.
Date issued //`Q/ 22/? Registrar of Vital Statistics �,
1 (�signature)
District Number j 60/ Place '7: AA, AV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Z � ��� �,N, ,�, ✓
Date of Disposition � Place of Disposition
W (address)
U?
CC (section) (lat number) (grave number)
pp Name of Sexton or Person in Charge of Premises it
/h� S ..Ml
Z ( se print)
LU Signature4._ Title Pttot
(over)
DOH-1555 (02/2004)