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Hammond, Sheridan
# 520 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex She..r-%clan De 1 ber-I ti am(WY NO i`�I Date of Death ti ' Z \Z©i Age If Veteran Dofates q 5c1 - U.S.Armed Forces, I cito 1 Pla'- - , City,Town r Village C h-Sie H wf Htreet Address on or 2 M I C 1e A3oi- R d Manner of Dea Natural Cause 0 Accident omic Suicide rl Undetermined n Pending ILI Circumstances Investigation at Medical Certifier Name Title a b r. C,' 1ai t--k.C) Address 02 PcuLt St 9 C►IQJ OJLO, 1,-N 12gO 1 De 'sate Filed District Number Register Number C' , Tow or Village C S- `>- 510 S q ❑Burjal Date 12 12.O t$ Cemetery ot Crematory p i v i e,uL) • DE matio ni Address OL,LICL_LOX- K—� O O Lt C1.t-A�'Ji.1�• i 12SOLI `•�remation � _ � � Date Place Removed Z ri Removal and/or Held and/or Address Hold Date Point of 0 Transportation Shipment 6 by Common Destination Carrier Disinterment Date Cemetery Address . ElReinterment 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 aRemains are Shipped, If Other than Above Address a 1:3"` Permission is hereby granted to dispose of the human remain e , ed above as indicated. Date Issued O (0-O b I$ Registrar of Vital Statistics c/lit C)u ' (signature District Number S(o S cD Place \ O LD‘r\ o\ �AC t . c r•= 01 this permit on: I certify that the remains of the decedent identified above were disposed of in a co Date of Disposition k1Z) lig Place of Disposition QK0.... LiOA-, (address) torta (section) A(lot number) r (grave number) O Name of Sexton or Person in Charge of Premises /r. Ar• ,l tad A (p print) Signature Title (RAI (over) DOH-1555 (02/2004)