Welch, June NEW YORK STATE DEPARTMENT OF HEALTH
8/3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
June Brister Welch Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/07/2018 81 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Castleton-on-Hudson Street Address Riverside Center For Rehabilitation And Nursing
Manner of Death®Natural Cause El Accident Homicide Suicide El Undetermined �Pending
Circumstances Investigation
Medical Certifier Name Title
Adetutu Adetona MD
Address
90 N Main St,Castleton-on-Hudson,New York 12033
Death Certificate Filed District Number Register Number
City, Town or Village Castleton 4124 27
❑Burial Date Cemetery or Crematory
10/10/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
Q Renterment
Date Cemetery Address
_3.
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
; 11 Lafayette St,Queensbury,New York 12804
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 10/10/2018 Registrar of Vital Statistics Pairaic Sean Ells(&ectromcaLTy Signed)
(signature)
District Number 4124 Place Castleton, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (0 In I I/ Place of Disposition L
(address
(section) (lot number) (grave number)
('
Name of Sexton or Person in Charge of Premises ittkv Sta*I
(please print)
Signature Title CROlet
(over)
DOH-1555 (02/2004)