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Holcomb, Gloria 4 r? NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex�t(or \o. _ �eociA -hot co h Date of Death Age If Veteran of U.S. Armed Forces, 1,201 I • 1 War or Dates 4 Y- Place ath f Hospital, Institution or City,�or Village F7- 1 Street Address )")z LS, -6-„‘.,,,v/ 4,44; )-"A-- S iet Manner of Death aNatural Cause ❑Accident El Homicide 0 Suicide rl Undetermined Pending 1 Circumstances Investigation_ W Medical Certifier Name ,) Title ,�/ Address ) L6/ Deat irate Filed District Number ./ I Register Number City,qoletior Village / -r //V,J — l ❑Burial Date Cemetery Crematory's ❑Entombment Address . remation aC JO?Cram. f J O. 'U .93`g `j - 1 Date Place Removed Removal I and/or Held 2 u and/or 1 Address g Hold i Date Point of c El Transportation Shipment • ci by Common Destination Carrier ©Disinterment Date Cemetery Address El Reinterment Date Cemetery Address I i Permit Issued to 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 IF Address -• IX l f✓<. Permission is hereby granted to dispose of the human re ns described above ' d tad. • Date Issued Z-02 J-020/7 Registrar of Vital Statistics (signature) District Number S y Place /1.,,/ / r. 7 2 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 141 Date of Disposition $JL3) 9 Place of Disposition 't:.4Us-ed errr¢4Orlo-%, (address) 1.11 Ni M (section) A(tor number (grave number) pName of Sexton or Person in Charge of Premises 4�(n, i^.�l{ z p (please pant) tit Signature Signature 4Title (Rom gir (over) DOH-1555 (02/2004)