Tucker, Timothy r ; # 76,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirstTimothy Middle Gilford Lafacker Sex Male
iiiiiii Datet03 Age53 years If Veteran of U.S. Armed Forces,
War or Dates
14 Place of Hospital, Institution
XXX Glens Falls r k,hester Street Glens Falls, NY 12801
City, Town or i age Street Address
ILI1 Manner of Death❑`(Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined Pending
W. Circumstances Investigation
fa Medical Certifier Na Titoroner
�'rmothy Ti
E. Murphy coroner
Addfe9laviland Ave Glens Falls, N Y 12801
Death C969stat
StfrktIC Glens Falls Distrio3atimber RegRegiggr Number
City, Town or Village 2o V
iiiii OBurial Date 05/09/2013 cemelbM Vi } iy
Mi ❑eEntombment Addrestueensbury, NY 12804
giiii['Cremation
Date Place Removed
Z❑Removal and/or Held
and/or Address
F= Hold
O.
Date Point of
16, Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
fliimi,❑Reinterment Date Cemetery Address
Permit Issued to Maynard D. Baker Funeral Home RegisOati86 Number
<s Name of Funeral Home 0//30
Address 11 Lafayette Street Queensbury, N Y 12804
iliiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
4
tit
'• Permission is herebyy/Q9/10ggra13ed to dispose of the human remains describ d above s in ed.
05nt Date Issued Registrar of Vital Statistics e
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k �
III Date of Disposition 3 W-ts; Place of Disposition -'t',,,�,t j,,,,f �(Vwc to r:w-
1 (address)
to
t (section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises A) �. 5ei -
�
2 lease print)
Ili
Signature Title CF.1rw1TO
(over)
DOH-1555 (02/2004)