Maxwell, Charles 4 11
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
t.:. Name First Mid a Last Sex
Date of Death t--� Age_ If Veteran of U.S.Armed o ces,
/ d- - 31) — ,�o / l J 5 1_ War or Dates / 161& — fD D 01
P - - of Death. i Hospital, instttutio r
. ;Ci Town or Village G(e rt S ,r� I t's { Street Address C /r n S ,(1 S 7 l'O S a 1 k 7
Manner of Death Natural Cause Accident []Homicide ElSuicideUndetermined Pending
Circumstances Investigation
fa Medical Certifier Name Title
0 I e rri 6A - Cvrvtec&.0 C1r- Of\e v-
Address
lidn.n• : Certificate Filed District Numt'-(
LRegis r Number
!_ +± ,Town or Village („({'14 r /7 s y \DO t L DK 3
OBurial Date
1 / Cemetery or Crematgcy
I Entombment 1 i/e tit e C r ey C --�v�l
A dresss� \
XI Cremation Q LS C oJ C.....J e e,, , by U\I )i`lv
. )-'2
Date Place Removed
Orl Removal and/or Held
and/or Address
Hold
Date Point of
Vti❑Transportation Shipment
0 by Common Destination
Carrier
.`` O Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
i
Permit Issued to Baker Funeral Home Registration Number
Name of Funeral Home
01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address -
Permission is h reb granted to dispose of the human mains d scribed a vs as it;rdi
Date issued ('}i bz,�O/� Registrar of Vital Statistics
(signatu e)
District Number 5./4 I Place �X^'�%�—��/�'
I certify that the remains of the decedent identified above were disposed of in accordan with this permit on:
W Date of Disposition //4011$ Place of Disposition f;A,4, t n
2 - (address)
it i
N
it (section) A(lot number) (grave number)
aName of Sexton or Person in Charge of Pr ises L 4'"44fr-
1 ( sepunt)
Signature Title - (Remit
142
(over)
DOH-1555 (02/2004)