Inserra, Richard NEW YORK STATE DEPARTMENT OF HEALTH ; •r-'
Vital Records Section Burial - Transit Permit
Name Fi Middle Last Sex
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,
Date of Age If Veteran of U.S.Armed Forces,
. 101W\2 -01 Z l9-4 - War or Dates V, -noxy1
#- Place • Death ; Hos tai, institution or
W City Town•r Village Qt le b))- i Street Address a9 _emu, strce.fi
Man - • Death Natural Cause Ej A ident 0 Homicide 0 Suicide ❑Undetermined 0 Pending Circumstances Investigation
la Medical Certifier Name Title -
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. Address - �_ � y ��� 1
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TfUC s • qieLl 11 eo f Register Number
De ' 'cate Filed district Number5� g
C' ,Town rVilacge 0t boY1Skt)i' i , 5
Date J { Cemetery or Cram �
: : aBurial I���3Ilio(g 7l i 1'& Pik)w) (Xe YICLIO -
❑Eritcmbment Address ✓
Cremation C9t your t o t 1'1S ri i_U f
Date Place Removed Li
Z Removal and/or Held
and/or Address
Hold
0 Date I Point of
N C1 Transportation 1 Shipment
0 by Common Destination
Carrier
Date i Cemetery Address
[]Disinterment f
Q Reinterment Date I 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
I- Remains are Shipped, If Other than Above
2 Address - ••
CC
P' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 q-31 aO 1 t Registrar of Vital Statistics L.Ad,k, y.. Q,co It
(signature)
District Number U ) Place DUctriSioviti
were of in accordance with this permit on:
I certify that the remains of the decedent identified aboveposed
) Date of Disposition f l 4:I II Place of Disposition groV Ado r,w„
2 (address)
CC (section) A (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises (A eittr SS% `
iat
Z (PP►in0 ^
Signature Title / E mut,
(over)
DOH-1555 (02/2004)