Dowes, John t `-s
NEW YORK STATE DEPARTMENT OF HEALTH # 1 9 b
Vitt Records Section Burial - Transit Permit
Nome r Fir o £c /t)--4( '
Dateo# AgeVeteran If U.S.Armed Forces,
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of Death
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�� of Deatlt �� c
w, . _. '7 rural Cause [QAccident [J� 0 Suicide 0 maimed 0 P�emclsrg
t Circranstances Investigation
Merfocal Certifier Name Title
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Address
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- ., { Cie Feed District r�r r /
1 � or CF`L s 6WS O1 ri0
Y N _ • Date Cemetery (.. D �/
['Entombment q /Z // "� lAddressr aJ t U/c-L..�
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K Date Place removed
0Removal
Address antgor Reid
5 Hold
" Date Poird of
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3�❑Transportation Shipment
by Common Destimdirm
\ Carrier
D Dnent Dade y Aridness
Date
} : P Issued to Registration Nunther
Name of Funeral Home Maynard D. Baker Funeral Home
�� �� il 9
€- Address 11 Lafayette Street
k Queensbury, New York 12804
Name of Funeral Firm Making Disposition or b Whom
\ Remains are Shipped.If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued U-1 / , 'a,/ri Registrar of vital Statistics L.�cAA,,).,,2. t.�
edenerund
District Number 5 60 i Place 6 lsz),,,s rcA i 1 S f N v
I certify that the remains of the decedent idenbged above were disposed of in accordance wdh this permit on:
Date of Disposition L)s l t-I I Place of Disposi ion {2,ft4 U. rrtnci d()tri
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K,- Name of Sexton in of Pt f (Lø ,r t rri[I+
(please print)
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(over)
DOH-1555(02/2004)