Holmquist, Geraldine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Geraldine D. Holmquist Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/f0a/20t12 93 years- War or Dates
-• Place o ea h Hospital, Institution or
Z City, To ei Street Address
Uj X Clcns f-� 2 Liberty�c e Glca Fall NN 1 801
Manner Natural Cause Accident Homicide 0 SuicideU. Undne ermin Rds P�n ng
Circumstances Investigation
la Medical Certifier Name Title
C
Address both Hutchins Md
2 Broad Street Glens Falls, Nv 12801
Death Certificate Filed District Number Register Number
:;% City, ToY 1 A l xx Glens Falls 560-1 565
:'❑B)irial ate Cemetery or Crematory
ill 1/2012 N
��l=ntom6riient - ��: ;~� �;,v:.sas�����'�
}
Address
:;;[]Cremation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
1519, and/or Address
h` Hold
U)
0 Date - Point of
i0 Transportation Shipment
f i by Common Destination
ni Carrier
Q Disinterment Date . Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Raker Funeral Home 01130
Address
11 Lafayette Street Queenshury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
LEI
tip - -
Permission is hereby granted to dispose of the human remains described-above as indicated.
Date Issued 12/11/2012 Registrar of Vital Statistics W C ,--,Q .N�^-'�`'
(signs ure)
District Number 5601 Place Glens_Falls) lv
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III Place of Disposition ,5 ccir Q�c i''7 ��"`
• Date of Disposition l Z`it��L _ P �� AA.,� `�
(address)
tiiC 6. 2-
CS ( n) (lot number) (grave number)
6 Name of Sexton or Person in Charge of Premises a� �'
(please print)
Ul
-1- Title U "CtiNal(please
Signature J
(over)
DOH-1555 (02/2004)