Engle, Laurie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
I aerie Ann Engle Female
Date of Death Age If Veteran of U.S. Armed Forces,
P 12/f1Bea/2Ch12 50 years War or Dates
lace o Hospital, Institution or
Z City, To i •••- Street Address
ua i• X Glens F Clcns I yo ital
Manner 4 Natural Cause Accident 0 Homicide Suicide ndefermined Pending
lV v Circumstances Investigation
al Medical Certifier Name Title
Addiessrices C Bollinger M D
100 Broad Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Tovuii)8VB'il ge„X Clcns Falls 5601 583
❑Burial ate^^^^ Cemetery or Crematory
❑Entombment Address,2"1"12 "nV 2 1 Pine',/inw Crematorium
` "
•
❑Cfemation Queensbury, NY 12801
Date Place Removed
Z ❑Removal and/or Held
and/or Address
w Hold
0-'11
o Date Point of
tili❑Transportation - Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
iiiigEl Reinterment Date Cemetery Address
Permit Issued to Registration Number
NA Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, ►SLY 1h804
Name of Funeral Firm Making Disposition or to Whom •
14 Remains are Shipped, If Other than Above
Address
tr
` Permission is hereby granted to dispose of the human remains described above as indicated.
1111111111 Date Issued 12/21/7019_ Registrar of Vital Statistics (..A) Cskj\i °
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition l /-! Z Place of Disposition at_ ul {g
2 (address)
C
(section lot nu er) (grave number)
Name of Sexto or P arge f Premises i d
p �r((please prin
la
Signature C-- Title _Ctetor4 _4(- _S
(over)
•
DOH-1555 (02/2004)