Weldon, Evalee 0- 5cJ
NEW YORK STATE DEPARTMENT OF HEALTH , .%.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Evalee Kathleen Weldon Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/20/2018 75 Years War or Dates
Place of Death Hospital, Institution or
m City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide Fl❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Scott Biasetti MD
Address
lee' 100 Park St,Glens Falls,New York 12801
5 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 497
`' ❑Burial Date Cemetery or Crematory
10/23/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal
and/or and/or Held
Address
Hold
Date _ Point of
• ❑Transportation -': Shipment
- by Common Destination
Carrier
i.
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r. Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
• Address
tt.- 11 Lafayette St,Queensbury,New York 12804
4Rk. Name of Funeral Firm Making Disposition or to Whom
- Remains are Shipped, If Other than Above
_a Address
Permission is hereby granted to dispose of the human remains described above as indicated.
z Date Issued 10/23/2018 Registrar of Vital Statistics AribertA Curtis(ECectmnualysigned)
(signature)
F District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
-04
Date of Disposition /D J ZS lit Place of Disposition en(Lw e "1
; (address)
(section) (lot number)/� (� (grave number)
• Name of Sexton or Person in Charge of Premises /, I"+drifr- Jtreir
I
(please print/� }M�Signature Titlent
(over)
DOH-1555 (02/2004)