Kendall, Natoyia c v‘ II 1//U
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middl Last Sex F
`Kca-tr) (rL �k-� Y,enCU l I
Date of Death Age— 1 If Veteran of .S.Armed Forces,
OS I Zo 110 ICI War or Dates .---
1 Place • " Bath ; Hospital, Institution or �k I
Z City, Town or Village M() r Pal , ; Street Address IS•j(p ic_o f ,
in Mann Death n Natural Cause 0 Accident Q Homicide 0 Suicide Q Undetermined ; Pending
l� Circumstances nvesti•-tion
Medical Certifier Name Title
UO fl\-&I Vu h n CUY orvL.r
Address 110
nC �as-I- r S4-r �J �j NV )7Uo
Death Certificate Filed r , L District Number ' Register Number
` ; City. ow or Village W\ J QC U ��
QBurial Date Cemetery o Cremato
j r`j ad o Ing_. Vi-C',O
1 D Entombment Address
°:,ICren,ation (-- UCKILair 'chi Q Uief21 abuU r N Y . I W y
Date Place Removed
it®Removal and/or Held
and/or ; Address
t Hold
01 { Date Point of •
0al D Transportation I Shipment
1 by Common Destination
Carrier
l:' Date I Cemetery Address
1Li Disinterment
3 E�,Reirtte rnnt Date i Cemetery Address
i
:.• Permit Issued to Baker Funeral Home 1 Registration Number
Name of Funeral Home
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1—i Remains are Shipped, If Other than Above
m—�
• Address _. _.
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date issued a-3/ / g Registrar of Vital Statistics 4 `4 4— _
(signature)
District Number 1/50 2. Place 7b4✓# 1 d r 14f a ic ea.e.L.,
tom' I certify that the remains of the decedent identified above were disposed/of in accordance with this permit on:
a
12.1 Date "'°`i Disposition Diy
p rilllI�' Place of Disposition �,,i:., (`, .fp, .
`" (address)
M' (section) of number) (grave number)
C
fn; Name of Sexton or Peron in Cha ge of Premises o,iy�. �'t-fir
2i �Jj (plealse print)
11:'i Signature �, 41 _ Title /Okiiiyt L
(over)
DOH-1 55 (02/2004)