Baulsir, Elmer NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transi P rmit
ii Name First n Middle , Last Sex
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s Date of Death Age p If Veteran of U.S.Armed Forces,
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Date Place Removed
❑Removal and/or Held
and/or - Address
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Date Point of
0 Transportation Shipment
by Common Destination
Carrier
<;❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M ay nar d b..€c ker Funeral 'No r1- - 0 \, TV _.
Address
11 Lakkyk_"He- SA• ) Queensbu,ry , Nev IorL 12 ot-A
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Permission is h e granted to dispose of the human r ins described above s indicated.
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Date Issu Registrar of Vital Statisti /®!'
(signature
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I certify that the remains of the decedent identified a were disposed of in accordance with this permit on:
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Ul Date of Disposition 3/►1115- Place of Disposition -ON Oh—AdressC �r
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CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises rM S -
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LS Signature A — Title (I2
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DOH-1555 (02/2004)
BAULSIR
7-LF1
�-\\ Lot No. Al -r.
dress 23 La rm C_ai_irt Nileanshiir NY 12RC14 Section NO.
vner Elmer & Jean Baulsir Plot Algonquin
to 6/13/00
A o o r o x 1_6 Superficial ft.
cation Bounded on North by Path , South by Eichen , East by Vacant ,
West by Vacant .
rner Posts
marks
ed No. (and changes) 3033
✓ment Record Paid in Full 6/13/00 ($175 . 00)
:ord of Interments
Elmer Baulsir 4/3.0/15 (cremains) V V
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1 No. 01
itAME BAULSIR, Elmer '
is
Age: 85
Cause:
Lot Owner: Elmer & Jean Baulsir
Lot # 61C, Algonquin
Grave M 1
Case # Cremains
Died: 3/1 /201 5
Interred: 4/30/201 5
Undertaker: Baker