Jefts, Charles NEW YORK STATE DEPARTMENT OF HEALTH
Vita!Records Section Burial - Transit Permit
Name First Middle Last Sex
CncL \es -IS W
Date of Death Age() If Veteran of U.S.Armed Forces,
LI I ) (1)1 `�3 War or Dates
Place of Dea , Hospital, Institution or ll- 0j0 )-'oc--)--
fj City,Town Vitlage C�It✓(�' Street Address
C Manner of Deat Natural Cause 0Alec"ident Q Homicide 0 Suicide ri Undetermined 0 Pending
W Circumstances Investigation
dMedical Certifier Name u9 a n€ i ^1 Title M Y
Address I b tC ec 920(, 0 U.P2ingburti f W /'2 `-/
Death Certificate Filed : District Number Reg' ter Number
City,Town or Village C.e09, _. 1 56 9 0
;OBurial Date I Cemetery or Crematory
`�I �( t� ire Via Cfrfria-frij
• Q Entombment Address �
Cremation C UC�,�(,CI7 LCOI 4 l yJ U•e•e,1 49UYV,�', Iv'�
Date Place Removed �Jf
Removal and/or Held
9 and/or .Hold I
Address
Q Date Point of
I.❑Transportation Shipment
el by Common Destination
Carrier
Q Disinterment Date i Cemetery Address
Reinterment S Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Baker Funeral Home 01130
: Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z. Address
tt
ILI
> Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ii/ q//g Registrar of Vital Statistics I 0. ` W re
( g )
District Number 5 6�Q Place V i 11Q 06 L.o c o ej `! i I 1
i; , I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1,Z6li Place of Disposition rh,•11-., _.
r (Lehr►
2 (address)
Lil
tf3
}r (section) A (tot number) (grave number)
CI of Sexton or Person in Charge of Pre ises S�'Att
Z / ($ease print)
W Signature Ci( y Title tkrvei M
(over)
DOH-1555 (02/2004)