Hart, Ruth i
NEW YORK STATE DEPARTMENT OF HEALTH - • ' =` ItIl�
Vital Records Section Burial - Transit Permit
Name First n Middle r� Last Oar Sex ,---
Date of Death K5.j,�� t g I Age _, { If Veteran of U.S.Armed Forces, —
I I (.9 War or Dates
} . P e of Death I Ho •' : Institution or
Z Cit Town or Village 6 F°�-U_ f Street Addres 3l o M ctAtrl Si . ( t)
0 Manner of Deatf.Natural Cause ❑Accident El Homicide 11 Suicide ElUndetermined n Pending
W Circumstances Investigation
tu Medical Certifie Name Title
Address
II--th Certificate Filed p7 �0. 1 District Number —‘ l Register tyurr�bef
etrown or Village tG'�� o�(p
❑Burial Date 513c71Z( ; Cemetery oremator
�g pint_ \OL.
0 Entombment Address
i* remation air 2-Ci ,., au_o buA.,...1 I IJ 4 12gCUy
IDate I Place Removed
Z Removal i Iand/or Held
2alor ; Address
- H
0 ` Date ' Point of
ei El Transportation Shipment
G1 by Common Destination
Carrier
E, Date } Cemetery Address
[i Disinterment !
Date I Cemetery Address
`- Renterment I
Permit Issued to I Registration Number
Name of Funeral Home Baker Funeral Home I 01130
Address
11 Lafayette St., Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
Address
IC
LU
CI" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ("-SR 1Z.01 Z Registrar of Vital Statistics )v CA, y L\;Jun
(signature)
District Number 5 b 0 i Place G t,,,.S l� 1) t
r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5( 1 (ig Place of Disposition �,,, 4h,,le,`
2 (address)
Lii
03
Et (section) Mn( ber). r (grave number)
p Name of Sexton or Person in Charge of remises RI J'1
4 Si nature
(please pnr)
Title [Pertlflot
(over)
DOH-1555 (02/2004)