Meacheam, Virginia I , e 57
NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section _ i „ ,,,, " , aBurial - Transit ermit
nj Name \First \ (bliShce L st S x
Date of Deat Age - If Veteran of U.S. Armed Forces,
1 4 21 t 0 (05 War or Dates
Place of Death MiCiq
Hospital, Institution or
iiiCity, Town or Village 1 Street Address
Manner of Death Natural Cause El Accident El Homicide El Suicide nUndetermined ri Pending
iti
Circumstances Investigation
at Medical Certifier --=1ek k Title �Vn „ o
... vcyAtdre,s7 ,Ai.._.,,c_ %, P e—IU +�
Death Certificate Filed District Number 515D Register�Number
City, Town or Village
❑Burial Date Ce e r Cre
1 lam
❑Entombment Address
':"Cremation 0.6e_.t S\DJL roZ (-25 k-1
Date Itlace Removed
Z ri❑Removal and/or Held
and/or Address
E= Hold
to
0 Date Point of
Di Ei Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
iiiiiiis ❑Reinterment Date Cemetery Address
Permit Issued to a ,� Registration u r
iiiig Name of Funeral HomeçV\Q7\ ,, 4
Address 1)3 fr
,!::.!::;!
. pal/44a 12.4itz)
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ili
CL
iinPermission is h eby g anted to dispose of the human remains described above as indicated.
Hi Date Issued —1 21 I(t Registrar of Vital Statistics j&A.A.,101
(signature)
District Number 575 ) Place A Q,- (
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I Date of Disposition 7`Z$itC, Place of DispositionfittOlta (
(address)
Ui
Mt
is (section) (lot number) (grave number)
cl Name of Sexton or Person in Charge of Premises ir
. L�#41
( lease print)
I Signature a - Title M
(over)
DOH-1555 (02/2004)
' Cremation Queensbury, NY
Date Place Removed
3❑Removal and/or Held
*.? and/or Address N
1:: Hold
tt
Date Point of ‘104 _
❑Transportation Shipment
0 by Common Destination
Carrier
`` ❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Iniiii Address
402 Maple Ave. , Saratoga Sp. , NY 12866
>> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address