Monroe, Eugene r 1 It62
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eugene Albert Monroe Male
<' Date of Death Age If Veteran of U.S. Armed Forces,
01/29/2011 68 years War or Dates
14 Place of Death Hospital, Institution or
5 City, Tow it Street Address Park St Glans Falls N Y
�(� XX GlPnc Falb
Manner of Death❑Natural Cause 0 Accident ri Homicide Ei Suicide ElUndetermined ri Pending
W. Circumstances Investigation
ill Medical Certifier Name Title
fl Patrick Rowley Mel
Address
Park St. Glens Falls
Death Certificate Filed District Number Register Number
City, Towrri?cYillft XX Glans Falls 5601 44
is❑Burial Date Cemetery or Crematory
<❑Entombment 111/30/2013 Pine View Crematorium
Address
❑Cicemation Queensbury. NY 12804
Date Place Removed
❑Removal and/or Held
1 and/or Address
M Hold
CA
Date Point of
giQ Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
lillQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Nliiiiii Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above —
a Address
It
,,
r!': Permission is hereby granted to dispose of the human remains de ri e abo as i c ted.
Date Issued 01/30/2013 Registrar of Vital Statistics
(signature)
District Number Place
5001 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 2-I-13 Place of Disposition X' 4.1 l ovirriv-,
(address)
Ili
tfl
it (section) (lot number) (grave number)
Name of Sexton or Pers in Charge of Premises PI1 St•►rff"
(please print)
( Signature Title CttL^"is-Tty_
(over)
DOH-1555 (02/2004)