Matraw, Patricia NEW YORK STATE DEPARTMENT OF HEALTH * ` S it 17°
Vital Records Section Burial - Transit Permit
Name Firstpatricia Middle Ann Laip'tatraw Sex Female
Date 109eat i3 Age75 years If Veteran of U.S. Armed Forces,
War or Dates
14 Place of .- Hospital, Institution
City To��
♦♦♦ VW( Glens Falls -i u Goodwin Avenue Apt B Glens Falls, NY 12801
, . Street Address
Manner of Death Jlatural Cause ❑Accident 0 Homicide 0 Suicide ri❑Undetermined Pending
Circumstances Investigation
lei Medical Certifier Name Ti
i raham Atkins i D
AddrtsCarey Rd Queensbury, N Y 12804
Ni Death C Distri tuber Regie�r Number
City, Town oV Glens Falls 4
❑Burial Date 05/09/2013 CernENig0i&5t Wry
0 Entombment Addres
❑L'�remation Queensbury, NY 12804
Date Place Removed
Removal and/or Held
2, ❑and/or
Address�„
Hold
0 Date Point of
tri El Transportation Shipment
G by Common Destination
in Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiig Permit Issued to Maynard D. Baker Funeral Home Registy Iligp Number
Name of Funeral Home 0//3O
gli Address 11 Lafayette Street Queensbury, N Y 12804
ill Name of Funeral Firm Making Disposition or to Whom
io Remains are Shipped, If Other than Above
2 Address
CC.
Lu
9i Permission is hereby granted to dispose of the human remains d crib d ab e a i 'cated.
' Date Issued 05/09/2013 Registrar of Vital Statistics G2 %� r�1
(signature)
District Number 5601 Place Glens Falls
lii
;.;.>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 5-00-13 Place of Disposition RoAkix., Crrmolottw.
(address)
Ili
tfl
IC (section) %J (lo number) (grave number)
Name of Sexton or Person in Charge f Premises ` le,�- 3/tiriff-
2
(�i/ease print)
J44 4
Si gnature Title
(over)
DOH-1555 (02/2004)