Robelen, Alma NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alma Harriett Robelen Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/12/2011 90 years War or Dates
1- Place of Death Hospital, Institution or
5 City, TIOCKOC' X Saratoga Springs Street Address Wesley Health Care Center
El of Death Di Natural Cause ❑Accident Homicide ❑Suicide 0 Undetermined 0 Pending
Lt. Circumstances Investigation
ui Medical Certifier Name Title
Ct Matthew C. Pender M D
Address
35 Gilbert Street, Cambridge, N Y 12816
Death Certificate Filed District Number Register Number
City, TdXfilCa X0faaeX Saratoga Springs 4501 479
[]Burial Date Cemetery or Crematory
❑Entombment 11/15/2011 Pine View Cemetery
Address
❑Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
H Hold
U)
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
Queensbury, N Y
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
tii
CL
Permission is hereby granted to dispose of the human remai s des riI i abor 'ndicate
Ei Date Issued 11/14/2011 Registrar of Vital Statistics �,.�
(signature)
lig District Number 4501 Place Saratoga Springs
``' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
z
tLI Date of Disposition) 1 /1 5/1 1 Place of Disposition pine View Cemetery,
2 (address)
tAi
CA Mohican 43 A 2
tX (section) (lot number) (grave number)
QName of Sexton or Pers n in Charge of Premises Michael Genier
z 4 (please print)
tit Signature Title Super ntencdent
(over)
DOH-1555 (02/2004)