Lathrop, Ericka NEW YORK STATE DEPARTMENT OF HEALTI
Vital Records Section Burial - Transit Permit
Name First Middle Last ` Sex
E r i c Lc Lcc±n ro p
Date of Death 11 I 19 17_oi l- 1 Age t9i.. 1 If Veteran of U.S. Armed Forces,
' r Dates
1- a Death -u qlospital, stitution or
W WM own or Village �l �° � treet ddress ��D sw
W anner of Deatl $ Natural Cause ❑Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investi.ation
uj Medical Certifier Name CI c c COM�O-.t.l. Title
Address
1 -1O Sf atQ. 12.0ufi e Ci,La It_ Guyctei Nk iZ`% k S�
th Certificate • '• District Number R ester Nur
City Town or V' 1 S �0.r,S �� t
❑Burials 7 1 6\2_0 Ci" Cemetery or Cremata
0 Entombment Address
Rc remation c,IL y .)Q 'sbur-V ,. tug i 2g011
Date I Place Removed
Removal and/or Held
fland/or Address
u) Hold
0 Date Point of
u) 0 Transportation i Shipment
ci by Common Destinatio.
Carrier
❑Disinterment Date Cemetery Address
O
Reinterment Date 1 Cemetery Address
Permit Issued to 1 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
I_ Remains are Shipped, If Other than Above
2 Address - -.
tr.
tt,l--
Cis Permission is hereby granted to dispose of the human remains +escri ed above Inds ted.
Date Issued Registrar of Vital Statistics ` L -47-"1 ( igna-t�rej
District Number:5%e,-j Place e_ _ —,�i � >r7�!HI certify that the remains of the decedent identified above were disposed of in accordanc permit on:
Z
UiDate of Disposition ///23I!1 Place of Disposition ?NO.., �'-..,. .�
W (address)
CC (section) /�ot number) (grave number)
pName of Sexton or Person in Charge of Premi L �r= ,�In+�
Z (ple print)
Signature G✓r (7 Title fiZkilri%���
(over)
DOH-1555 (02/2004)