Baker, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH ri.°6-
Vital Records Section # N Burial - Transit Permit
Name First Middle Last Sex
Elizabeth A Baker Female
Date of Death Age If Veteran of U.S.Armed Forces,
i. February 1, 2017 512 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death 0 Natural Cause n Accident n Homicide Ell Suicide 111 Undetermined Ej Pending
W Circumstances Investigation
u Medical Certifier Name Title
W Dr. Micheal Miles, M.D. Dr.
0 Address
100 Park Stree, Glens Falls, NY 12801
Death Certificate Filed District Number r Register Number
City,Town or Village Glens Falls 5 -U C`)( S'Z_
❑Burial Date Cemetery or Crematory
February 7, 2017 Pineview Crematorium
❑Entombment Address
n Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
- and/or Address
I' Hold
Date Point of
0 n Transportation Shipment
Da by Common Destination
Carrier
Date Cemetery Address
a �Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped,If Other than Above
X
W Address
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/6) I-'-r Registrar of Vital Statistics bk3C.,W NR.-
(signature)
District Number 5'DcD( Place Glens Falls,New York
!• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
wDate of Disposition 02/07/2017 Place of Disposition Pineview Crematorium
2 (address)
0
O (section) :,(lot number) (grave number)
O Name
ILI of Sexton or Person in Charge of Premises, / r,r it o,At it
(please print
Signature �� a Title (11C YIO('
(over)
DOH-1555 (02/2004)