Duell, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First *Ole Last Sex
G�4 z 0g�7H- II j&. F
Date of Death Li
1 3 a013 Age 9/ If Veteran of U.S. Armed Forces,
War or Dates
}.. Place Bath
Z " , Town ` ti— t Addre (fib Qu os),nsbU kki Ave`
w Manner of Death Natural Cause O Accident O Homicide O Suicide ri O Undetermined O Pending
lt�� Circumstances Investigation
• Medical Certifier Name?a,ta r 1 ion Title
1 iti6
Address 2 I ro(x3a-I e Cen+er A�
�J , ���Sr�R-U-S� JvI l.,Rd/
Death Certificate Filed Distri Number Regi$ter Number
, Towr ili Lx r L�,`J
OBurial Date y/3/a)/3 rematoryi�i!�-VLQ,k rl ejr ,
i ❑Entombment �
Address //-�
Cremation Qu ed ., Qui2/2mS r7
Date Place Removed
3❑Removal , and/or Held
F- and/or Address
Hold
0
Date Point of
85 O Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
O Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home �,al l-1 J d �• Da ker- }- LUlei-c. ( H oir 0 1 t 30
Address
11 La-rcL jc4 k Sir ccA , Queensbury , NeNA! `tor K 1c so(1
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
• Address
CC
W.
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued U3L�0}3 Registrar of Vital Statistics Q. (ALIA
(signature)
District Number ---10 c--) Place ci,,,,, bc C._._- V.,0 ,,
I certify that the remains of the decedent identified above were disposed fin accordance with this permit on:
W Date of Disposition 4-c''3 Place of Disposition "✓ i rv-c ter,4►2
2 (address)
ILI
in
IC (section) 1 (lot numb (grave number)
p Name of Sexton or Pers n in Charge,of Premises firs 3Piry
il-
;'Z II (please print)
ILI Signature l l� Title t eE ti Kroe
(over)
DOH-1555 (02/2004)