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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
.-.q: Name First Lai. Middle_ Last Sex nai A
. '
,:• U'' Ifec
Date of Death i i
Age If Veteranro—f U.S.Armed Forces,J
0-4 ii.) S L.Q.Le War or Dates ---
, ..
Death I Hospital,Institution or
:ADTown or Vdlage (5; (SI) S ratis I Street Address / c.-- 'l204,/ St
_ ner of Death 2)4atural Cause 1:3 Accident 0 Homicide 0 Suicide 0 UndeWinkled 0 Pending
IL1 Circumstances Investigation
ta Medical Certifier Name.-- Title
Ci I / mottniti inur O'vkj Co(by\.e.A e
... . . Address r.
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. *HZ)i 04,lie JOUt t CA24e,d1V2u. e-1 1.-2-g O'1
-if Certificate Filed 1 District Number . ...,... , Register Number 595
--..1 Olti.)-own or Village -3, (eri4 c--6.1a-, (--9 D.-0 1
* :urial Date 11 q ij II Cemetery Cram i?
1 ite Lit.0;3
ClEntorribment Address .....3.
emation 00c144_1-it ?oc,tall uN;r-d-li iI')
naMOVete Date Place Removed
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...-t aridjor Address and/or Held
Lt Hold
fai
Date Point of -
et D Transportation Shipment
by Common Destination
Carrier
:... t, sinterment Date Cemetery Address
I u lI
s terment Date Cemetery Address
Fiin
Permit Issued to Registration Number
Nara of Funeral Home Baker Funeral Home
Address •
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
l--- Pen4ns are Shipped, If Other than Above
_
a.' Address
-
--I''' Permlaelon is hereby granted to dispose of the human remains described above es indicated.
I. 1
Date issued 1 1. 19 i 2.0 1,,(1( Registrar of Vital Statistics (.,1\) N1/4A4.-teNQ W.)11,14St
(signaturo
. '
District Number SEA,, Place 6 csvv,..3 FrA ki\ i tv y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-7
11,1 Date of Disposition It 1.43 id Place of Disposition 0,-., liv cc'-
(address)
tit
fa
(section) - Pot (grave numbed
01
oi Name of Sexton or Person in barge of Pr - es Itri;: jaw 41?
ZI (please pt,t)
Ul Signature Title • WI rim__
(over)
e01-1-1555(02/2004)
• •