Eichen, Laurie -46 6�L
8 YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U. rmed Forces,
War or Dates
PI e o ea h ' Hospital, Institution or
82
Cit Town or Village Street Address
Manner of Death Natural CauseEa" Accident Homicide Suicide 0 Un-determineff Pending
Circumstances Investigation
Medical Certifier Name Title
dress
Death Certif e i e ' ' Falls,Glens Dis ri cf T tumber TFRegister Number
City, Glens Falls 5601 l2
ate Cemetery or Crematory
❑Burial
Address
Cremation
Tn of gaamsbary NY
Date lace Removed
Z❑Removal and/or Held
•• and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home
Address
Name of Funeral Firm Making Disposition or fo Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above asjjtdicated.
Date Issued cj C Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls, BY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition — ( Place of Disposition DI k h Iq C R
2 (address)
LU
W
X (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises al i r Al CL ff2-
(please m)
Signature Title e kazhaTaeY -`/%—
DOH-1555 (10/89) p. 1 of 2 VS-61