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Kershaw, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH , Burial - Transit PermitVital Records Section Name First iddle last Sex L/ fr3L-77—lt _ J1 Ow rig-' k&-n-sm91,7 _ fcr/1 et t' , Date of Death I i Age If Veteran of U.S. Armed Forces, a? / War or Dates /6 Place eath ` Hospi nstitutio�ii City, Towner Village Q u ei c( I Street A ress (&),)Yi. Jr") C(5-‘ti 7— , Manner of Death Natural Cause L�Accid nt Q Homicide �Suicide 0 Undetermined Q Pending tut Circumstances Investigation Lu Medical Certifier Name / Title CI �AWIerZ 19'L4uJ /t/ b Address 9 r' Q / �) v�.us uvuj ,/V f Z� Deat ' icate Filed I Distric't`Number Register Number Ci ,Town Village 0 U 1�s.— c i 1 S�0 511 1 Og ❑Burial Date i Cemetery Cremato ? , ©Entombment 2-`1 / 7 I p ^)cr V/iv Address Cremation Q u 12)--k 6 ._,. Q U i 'it1L Q cm: r /11/ Date Place Removed Removal and/or Held ... and/or Address !/! Hold i 0 Date Point of Di 0 Transportation Shipment a by Common Destination Carrier Q Disinterment Date I Cemetery Address Reinterment Date Cemetery Address I t Permit Issued to Baker Funeral Home Registration Number Name of Funeral Home Address 11 Lafayette St., Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above X Address .. 1 to >t Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued ?-a9 -at?I 1 Registrar of Vital Statistics --I2 a.lk v. .k j (signature) District Number S '? Place 0 U e en bV(3 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Iii Date of Disposition $)311c Place of Disposition FIo,I .a Cleterij o rss--- us (address) to a: (section) /(lot number) (grave number) pName of Sexton or Person in Charge of Pre ises f Ar'sfopt,r S tA4i (` Z p (Please pant) i Signature _ CJ �(� Title 1' .11 A i` - (over) DOH-1555 (02/2004)