Sheridan, Martin • 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Thomas
Sex
Martin Thomas Sheridan Male
s' Date of Death Age If Veteran of U.S. Armed Forces,
06/13/2011 94 years War or Dates
14 Place of Death Hospital, Institution or
)01XX Town orb Granville Street Address The Orchard Nursing & Rehab Centre
Itit
Manner of Death Natural Cause D Accident D Homicide D Suicide D Undetermined D Pending
1 Circumstances Investigation
til Medical Certifier Name Title
Carl Beckler M D
Address
278 Vt Route 149, West Pawlet, Vt 05775
Death Certificate File4 , District Number , ..ARegist_erNumber
X749XTown orXXI Granville 5756
[Burial Date Cemetery or Crematory
06/14/2011 Pine View Crematorium -
;. DEntombment Address
OCremation Queensbury, New York
Date . Place Removed
❑Removal and/or Held
and/or
h+w 'Address _ _
Hold
0 Date Point of
Transportation Shipment
C by Common Destination
Carrier
0 Disinterment Date_ Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home O//q 7
Address
11 Lafayette St. Queensbury, NY
` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
1
Permission is hereby granted to dispose of the human remains described above as indicated.
* �'
r Date Issued 06/14/2011 Registrar of Vital Statistics UC� L G� .
(signature)
District Number Place
5756 Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ui Date of Disposition 6..,t)-A,II t n e tb
Lt Place of Disposition !e Cr,e .4 r,
".` (address)
ILI
40
CC (section) (lot number) (grave number)
0 �r
CI Name of S exton or Pers4on in Char a of Premises (' vi®`t� i`U»e Ile
�� Y (please print)
t Signature .�s� Title C 1'�vn e,r7 .
(over)
DOH-1555 (02/2004)