Noakes, Alan /5v
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name AFiist Middle. Last Sex
t-a- 1 V /�Oa t4 • 7Ylak,
Date of Death Age If Veteran of U.S. Armed Forces,
3- , g-Jo/3 —]7 War or Dates ,o
I. Place of Death Hospital, Institutio or /,^ ,�I
Z it , Town or Villagee1 Oqq ' Street Address a/-p � I((JCL L1ZI
ner of Death Natural Caus+ei A cident Homicide Suicidedetermine ending
LU Circumstances ❑Investigation
Lu Medical Certifier � e F" J _I/tle 0 0
Address l /V f �6�
s< Death Certificate Filed Di trict Num r _ Regist& ber
j'fown or Village • 7r 3:A T 3GA SPP S . 4 5 G/ ��
❑Burial Date A
! r 9 id-0/3
gtir or Cremat y
❑Entombment V,l'Q'.tt� /recce rcl L
Address
iiiiiiiEtCremation WIA-eQ41443 i,L.it,cd - /a,?O4
Date PI Remdved
Removal and/or Held
9. ❑and/or
Address�
Hold
Date Point of
o Li Transportation Shipment
CZ by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment •
Date Cemetery Address
PermitameIssued to t1f1L ��-�-2�L�..Q 1 Rer dt��rgjstration Number
''` Name of Funeral Home / — --
> (2. -1
0.1 /, ,� is 5V�
iiii Name of Funeral Firm Making Dispo is'r on or to'�'hom
Remains are Shipped, If Other than Above
Address
CC
111 .
i,aii Permission is hereby granted to dispose of the human remain ribed above as indicated.
gi Date Issued jh /(� Registrar of Vital Statistics �- y,
I (signature)
111 District Number 4 3/ Place SARATOGA SPRINGS
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tit Date of Disposition 3 2_'(3 Place of Disposition Pw4 Vim,/ Cloaf,_.,,y-
�
2 (address)
Ill
te
(section) ' (lotumber) (grave number)
Name of Sexto /r.% er n in Charge of Premises �"O 4. � n
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z ''``11 (please print)nt
44 Signature C� Title (rd14i'i�aL 4: 7'
(over)
DOH-1555 (02/2004)