Masten, Audrey NEW YORK STATE DEPARTMENT OF HEALTH } ... Tr n i- o
rml Vital Records Section Burial
a st t
Name First Middle Last Sex
Audrey L. Masten Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 19,2018 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 42 E. Holcomb St.
LL{' Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
ra Medical Certifier Name Title
Cv Dr.John Sawyer,MD
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register umger
City, Town or Village Johnsburg 5655
❑Burial Date Cemetery or Crematory
El
Entombment October 23,2018 Pine View Crematory
Address
Ei Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
cn
O Date Point of
u) 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
EI- Remains are Shipped, If Other than Above
• Address
11.1
IL
• Permission is her by ranted to dispose of the human rema' s •escribed� above ass indicated.
Date Issued CT Registrar of Vital Statistics � 2 l/ e (01
-
(signature)
District Number 5-& �3� Place Ic 0 C.), .. j1,lvt r(3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to/1.3MA Place of Disposition .f?.t ., sit ris—
W (address)
U)
O (section) (lot number( (grave number)
pName of Sexton or Person in Charge of Pr mises (�nrk�f1k r J p+*"1$
Z ' (please print)
LLI
Signature ..1— Title tNAlDO
(over)
DOH-1555 (02/2004)