Holman Sr., William wilpgro,4 , v
, ,,,h,e:
NEW YORK STATE DEPARTMENT OF HEALTH f
Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
W i 11 y o..M • . 401 m a; ,
Date of Death I Age I If Veteran of U.S.Armed Forces,
b, 1'2 t - i Co'. I War or Dates
ir- Place of Death ; Hos•i •tution or
W ct Vill� 0 o age �'4u 0'1 Fs A 4 treet Addre 1 2-4- Mown' .
ci Manner of Death LaNaturaause i Accident ❑Homicide ❑Suicide 0 a Undetermined Pending
ILICircumstances Investigation
uniMedical Certifier Name C-�\'1 can Title
ci pr, -& 1., b
Address
I 'Z. Pal k_ Si.} G LoA'a_ F } 1z-BO 1
Death Certificate Filed , District Number --4 Register Number
City, Town o. ill t�v $n I ! �`5 7 !e 5 0�
❑Burial Date r Cemetery o(Cremator�+
Address \ t ,
QEntombment `-\ ,1- n Pi rlf, v 14 up
Cremation a\ CL.1u r b_ . , i1 a o ArLabt ,L i1 L t �f I7�O'-\
I Date ' Place Removed
Z Removal and/or Held
Q Q and/or 1 Address
- Hold i
0 Date Point of
Q Transportation Shipment
c by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
t Remains are Shipped, If Other than Above
'"Address
ILI
ti Permission is hereby granted to dispose of the human rem - described above as indicated.
Date Issued '�(-,', -r ()i'? Registrar of Vital Statistics -�_4,1,_
(signature)
District Number 5 7 (c, Place fi O___e
I certify that the remains of the decedent identified above re disposed of in accordance with this permit on:
gDate
of Disposition II I-31 lJ Place of Disposition Q U,,,,, /Maly,,.,
(address)
LU
(l)
CC (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Pr ises ILPL .S- .ti1'
z /1, (pase print)
Lt Signature Lam' Title • lei 6 mI iOt.
(over)
DOH-t 555 (02J2004)