Proper, Louise • 7 zg
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section i Burial - Transit Permit
Name First , Middle Last Sex
Louise I.Proper _ Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/05/2018 85 Years War or Dates
Place of Death Hospital, Institution or
",1, City,Town or Village Johnsburg Town Street Address Adirondack Tri-County Nursing And Rehabilitation Center,Inc.
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined El❑Pending
t Circumstances Investigation
49
in Medical Certifier Name Title
Ellen Deprey PA
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
_' City, Town or Village North Creek 5655 22
❑Burial Date Cemetery or Crematory
09/07/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
rit and/or Address
Hold
in Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date r retery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
'It Name of Funeral Home Alexander Baker Funeral Home 00037
-; Address
3809 Main St,Warrensburg,New York 12885
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.
=b. Date Issued 09/06/2018 Registrar of Vital Statistics xp.tkteen C.Lorah(ECectronica1TySigned)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on:
In Date of Disposition 111 III Place of Disposition ' L- ( .to--
2 (address)
til
(section) lort number) (grave number)
rtName of Sexton or Person in Charge of remises ��' � �044itt
//� (pie e print)
ki
Signature G�r� Title Mg1OIL
(over)
DOH-1555 (02/2004)