Gebo, Elona NEW PORK STATE DEPARTMENT OF HEALTH l
Vital Records Section Burial - Transit Permit
Name First E t pna_ Middle H .
Last cue �o Sex F-
Date of Death I Age l if Veteran of U.S. Armed Forces,
3
IZ4l g I 1 7 ' War or Dates
Place Death H itution or
l Citl,<Tow0 or Village C-')L-L� �' . Street Address 1 SLA r-r e.j l e 1 d S Dr•
W Manner of Death SIN Natural Cause Accident 0 Homicide 0 Suicide Undetermined Q Pending
Circumstances Investigation
W Medical Certifier Name Title
O Dares G -h - Grubbs 1 _,Lp
Address
10 Z P 0,-A-AC_ +,j G U-Kz- To-11 n ) ►.-).-) 128O 1
Death Certificate Filed ; District Number r Register Number
City, tow or Village � ° �'�-'-1 " 9 I
OBurial Date ..9- I S12418 Cemetery orCiemata e
P%Ili_ NJ te_ .v
❑Entombment
Address a� 1( , feed, , c �L o b U 0.4 \2BCLA
! Cremation , �-{�(
Date Place Removed
Z Removal and/or Held
2�and/or ` Address
Hold
Ul
O I Date } Point of
U�3 El Transportation I I Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Q Reinterment , 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
2 Address -
CC
1- Permission is hereby,granted to dispose of the human remains described above as indicated.
Date Issued 1 - --)O 19 Registrar of Vital Statistics `--'0,44-A 'k.).�. Qwt—
(signature)
District Number rj 1 5 ''7 Place LP 0 e e (1 S A V(ii
fi ,,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
U1Date of Disposition 1 I 1.41% Place of Disposition P,,,U_ (�•rwT _h .
W (address)
U)
CC (section) ,fot number) es (grave number)
pName of Sexton or Person in Charge of Premises ( n s"%LIP
Z (plea nt)
iLiSignature _ `"'� Title Ck /►l1'(D2
(over)
DOH-1555 (02/2004)