Sisti, Mary NEW YORK STATE DEPARTMENT OF HEALTH
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Sisti Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 11,2018 95 War or Dates
, Place of Death Hospital, Institution or
'Za City, Town or Village Johnsburg Street Address 15 Crane Mountain Road
p, Manner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
la Circumstances Investigation
Medical Certifier Name Title
0 Kate Saur Jones
Address
,Schroon Lake,NY 12870
Death Certificate Filed District Number Regist r Number
City, Town or Village Johnsburg 5655 (-??
❑Burial Date Cemetery or Crematory
❑ January 15,2018 Pine View Crematory
Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
i a Remains are Shipped, If Other than Above
2' Address
CZ
Permission is hereby rant to dispose of the human re i scribe. • ,o a as in . ated.
Date Issued / /J rant
of Vital Statistics a(/ _ / , •7i�
(signatue) j
District Number 5655 Place Johnsburg
t
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 /j 1,/!5 Place of Disposition ?.liLl ewe
2 (address)
W
Cl)
re (section) l` (lot n tuber) (grave number)
pName of Sexton or Person in Charge of Premis s G,�„,l S`i4'
Z (plese print)
W
Signature Title
(over)
DOH-1555 (02/2004)