Cyr, Rose t # 61c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
pi Name First Middle Last Sex
"
Rose C.Cyr Female
Date of Death Age If Veteran of U.S. Armed Forces,
NE 08/11/2017 70 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
• Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 431
❑Burial Date Cemetery or Crematory
08/15/2017 Pine View Crematory
['Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i.
Permit Issued to Registration Number
to Name of Funeral Home Alexander Baker Funeral Home 00037
it Address
ttl 3809 Main St,Warrensburg,New York 12885
At
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/15/2017 Registrar of Vital Statistics Pp6ertACurtis TECectronicaltySigned
(signature)
District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition dlii.11)Place of Disposition f ev.u.f C a..,
• (address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of remises L'�°J +µme
(p ase print)
Signature 4 Title CQ4P
(over)
DOH-1555 (02/2004)