Vanderwarker, Nancy NEW YORK STATE DEPARTMENT OF HEALTH
TU CI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancylee VanDerwarker Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 22,2006 67 War or Dates No
Place of Death Hospital, Institution or
Z City,Town or Village City of Glens Falls Street Address Glens Falls Hospital
WLa Manner of Death ElNatural Cause ❑ Accident ❑ Homicide ElSuicide ElUndetermined ElPending
W Circumstances Investigation
V Medical Certifier Name Title
W CITimothy Murphy Warren Co.Coroner
Address
52 Haviland Ave.,Glens Falls,NY
Death Certificate Filed District Number Register Numbe
City,Town or Village City of Glens Falls 5601 1 2-
El Burial Date -Cemetery-or-Crematory
3/29/2006 Pine View Crematory
❑ Entombment Address
IN Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
Q and/or Address
I Hold
.63
Date Point of
N ❑ Transportation Shipment
by Common Destination
la Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00036
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
- Address
tr
dPermission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/23/2006 Registrar of Vital Statistics 12.43 -A j 1A
(signature)
District Number 5601 Place City of Glens Falls Clerk,Ridge St.,Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— „._, � _
LZ Date of Disposition 3 -- 30 -p(o Place of Disposition , ' NE ,.I 4/ C-l�.�t.�r.r r fC.1J 1 U /L�
(address)
W
co re
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises C.9'bet (z 6,1�i9.A1--3---
Z _ (please print)
W Signature GC 9` Lp Title CA !`'l--4' C)
DOH-1555 (02/2004) (over)