Reichenbach, Roberta NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roberta Lee Reichenbach Female
4 Date of Death Age If Veteran of U.S. Armed Forces,
11/21/2018 82 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Manner of Deathi_j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
Jean Flanagan MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward 5755 68
❑Burial Date Cemetery or Crematory
11/26/2018 Pine View Cremetory
❑Entombment Address
W
®Cremation Queensbury Town, New York
„r Date Place Removed
in❑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
r 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.
s Date Issued 11/26/2018 Registrar of Vital Statistics Aimee Mahoney(ECectronicallySigned)
(signature)
District Number 5755 Place Fort Edward, New York
fa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II—? -' Place of Disposition ;,,Q, v e,►,J Gf+✓r►ti c/
Lu (address)
5 (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises TC P"( 3 S ;',r- S
at (please print)
111Signature �4i ,ne ' Title t-rc t of
(over)
DOH-1555 (02/2004)