Harrington, Alice 4 N. # 2-7 9
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
Name First Middle t Sex
' . �LIGGti
'Su...)6.r 1*d roc I,v 4 7n),,.) 1 Fen,ter
Date of Death ' 1 Age I If Veteran of U.S.Armed Force,
L.04 1� c?I [ War or Dates .,jt 4
v. Place ,{Death Hos ital. in on or
`i citv ow,),r Village 73.6 L N.•i treat Addre �f Y 4�D �R LSD is
0 Manner of Death Natural Cause Accident []Homicide [�Suicide
ri Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
CI __Ili CY eu.( 6 L /`i • 6.
...: Address 1
7(0-) .fm^s !r,�, t Jb t ,Js is un-4, Ay
1 Death Certificate Filed District Number aI Register Number
-.: F City. oxi.aor Village go c.76., €
OSuriai Date ) i Cemetery or reato
1{ l� 1 mri,.1 e- V>IA..)D EntombmentiAddress
`.:':, scalar on 1 Q U kg-J � � (3U c.�b.Js 13 i A
r y i l Date I Place Removed
O 1: mo fa 1 and/or Held
- a nc!for i Address
Hold •
0col
1 Date 1 Point of •
i Transportation ' I Shipment
0 ,Ar Common I Destination
J Carrier 1
-`"I Date Cemetery Address
oistnterment 1
Date 1 Cemetery Address
Permit Issuedo ta 1 Registration Number
::;1 Name of Funeral Home
Baker Funeral Home 01130
f Ac371 c:�s
11 Lafayette St., C,ueensbury, NY 12804
NaTiG of Funeral Firm Making Disposition or to Whom
t 1 Re:,<E iris are Shipped, If Other than Above
a(-�'�l �y ..
Cg..�.ap
..1 Per3u_ission 3s hJ3)J
�eb gr-eea�ed to discos cf the human remains sde b above es indicated.
i
1 Date issued LRegistrar of Vital Statistics si Ly.,�,i'N-'ti-- _
(s gnat )
• District Number 5 U Place %' ��U
t= I cer zv that the remains of the decedent identified above were disposed of in accordance with this permit on:
gl Date • Disposition h1'-9 11 d Place of Disposition P,r 0.—.. '-kiv,
I
WI (address)
i�
W
M (section) flat number) (grave number)
a; Name of Sexton or Person in Charge of P ises �►, 1p L-- ,,.+IR'
c
i (pose Prim
, I Signer ure Title (r/t till ..a,
i
(over)
DOH-1555 {02/2004)