Voll, Eugene 44
NEW YORK STATE DEPARTMENT OF HEALTH IS3
Vital Records Section t Burial - Transit Permit
r Name First Middle Last Sex
Eugene J. Voll Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/16/2012 84 years War or Dates 1945-1946
of Death Hospital, Institution or
owr 3F I..r4 XX Glenc Falls Street Address Park St(=,lens Falls N Y
ner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
U.
tu Medical Certifier Name Title
Jennifer Stratton M fl
Address
14 Manor Drive Queensbury, N Y 12804
�S>:air Certificate Filed District Number Register Number
Ci ownkoR I XXX Glens Falls 5601 128
ET--Burial Date Cemetery or Crematory
['Entombment Pine View Crematory
Address
Cr,.semation Queensbury, NY
Date Place Removed
Z Removal and/or Held
9❑and/or Address
H Hold
U)
0 Date Point of •
It❑Transportation Shipment
d by Common Destination
iiV Carrier
❑Disinterment Date Cemetery Address
BiiEl Reinterment Date Cemetery Address
ieiiPermit Issued to Registration Number
iiii Name of Funeral Home Maynard D. Baker Funeral Home 01130
s Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
Ili
Permission is hereby granted to dispose of the human emains scribe above as ind cated
Date Issued 03/19/2012 Registrar of Vital Statistics / /�_�
sign ture)
District Number 5601 Place Glens Falls / `
Lti I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I�• Date of Disposition 3 -.a a—)atZ,Place of Disposition �'/le 0 t'@cif C rev- '(c c:L.0 v✓1
(address)
Ili
CO
CC (section) (lot number) (grave number)
ti Name of Sexton or Person in Charg of Premises < <'rry 04 by (3fv ri ell'
.---�_.iii (please print)
Signature Cl � (34-4,- Title C f c y,-7Q�c -T l�S •
(over)
DOH-1555 (02/2004)