Garb, Carl t A
it
NEW YORK STATE DEPARTMENT OF HEALTH • I •
Vital Records Section Burial - Transit Permit
,
, Mic i Name First s le taat S
(.t 4- � ��Z �
Date of Death A. If Veteran of U.S. Armed Forces,
L. .ir2..
_<` �� a War or D elr 2 - &2
Place th ti Hospital jnstitution `
City, own o�Ila e C Street Address I '
ti Manner vi De—at... Natural Cause 0 c . ent 0 Homicide Q Suicide ri Undetermined ❑Pending
Circumstances Investigation
19 Medical Certifier Name Title \
Address
ilis De 'icate Fil ct Number e i ter Number
:y C• ,Town o Villagk t.uZ �6 (_c c p c
DateCemetery o Cremato j
0 Burial tf/Z 1. // ' p
-ki ci- .lit e
Address I
emation L vAj, � 1f ubt<"!C( 4,7 „ (a l
Date Place Removed " L
Z' Removal ' and/or Held
-❑and/or Address
ti Hold -
0 Date Point of
Q Transportation Shipment
Li by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Maynard D.Baker Fueral Home Registration Number
a4 Name of Funeral Home j� Lafayette Street G/13 U
} Address
:FLAT Queensbury,NY 12844 -
L� Name of Funeral Firm Making Disposition or to Whom •
'" Remains are Shipped, If Other than Above '
Address
tril
:'}1 Permission is hereb granted to dispose of the human re ains described move as indicated.
iN
Date Issued ()Registrar of Vital Statistics Cl /68 ��
(signature)
111 District Number LQc Place J 0 0,
T I certify that the remains of the decedent identified at3ove were disposed of in acccance ith this permit on:
i r� \\
ZDate of Disposition ti Wilt Place of Disposition �'rw�u..) (rt"-efori..,
(address)
to
(section) / (lot number) -� (grave number)
GName of Sexton or Person in Charge of remises t1sr, l JaM
(please print)
i1 Signature Title akrrrit'1ri1-
(over)
DOH-1555 (9/98)