Baker, Evelyn 1 * 2�2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Evelyn Baker Female
Date of Death Age I If Veteran of U.S. Armed Forces,
April 1,2017 95 War, Dates
• Place of Death Hos Institution lirondack Tri-County Health Care
City, Town or Village Johnsburg S Address Center
'At. Manner of Death X Natural Cause I l Accident omicide Suicide Undetermined Pending
Circumstances Investigation
F Medical Certifier Name Title
James Hindson Dr.
% Address
'{KLQ}Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
z City, Town or Village T/O Johnsburg ,.ce;,.Se-S — 1 O -
II Burial Date Cemetery or Crematory
Ill Entombmeryt April 3,2017 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
na£; Permit Issued to Registration Number
✓ ; Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
: Name of Funeral Firm Making Disposition or to Whom
° . Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human" ins describe above as indicated.
Date Issued 3-11,2)0761 Registrar of Statistics (=J . J L (signature)
,,• District Number 5 S3 Place r�p gf3.2.6 "'/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition '//St7' Place of Disposition MVkt-f Lc ot.---..
W (address)
CO
CL
O (section) /' (jot number)(�4� (grave number)
p Name of Sexton or Person in Charge of remises C hr,t hir- . v�4lit
Z ({lease print)
w Signature s' Title GfiniTD ,
(over)
DOH-1555 (02/2004)