Baker, Edith VG/Go/6Ula LSVN 1e:417 L.AA 51710Y.17/U aonaiason r ljQ01/Q04
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial . Transit Permit
Name First Middle Last Sex
Edith L,Baker _Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/22/2018 99 Years War or Dates
Place of Death Hospital, Institution or
e- City,Town or Village Glens Falls Street Address The Pines At Glans Falls Center For Nursing&Rehabilitation
Manner of Death ral
iej Natural Cause ❑Accident ❑Homicide 111Suicide ❑Undetermined LI Pending
Circumstances Investigation
rd Medical Certifier Name Title
Kenneth France MD
Address _
i 170 Warren St,Glens Falls,New York 12601
Death Certificate Filed District Number Register Number
City,Town or Village Glens Fells 5001 104
l
❑Burial Date Cemetery or Crematory
02/26/2018 Pine View Crematory
7; ❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
1, Hold
,y Date Point of
rr ❑Transportation Shipment
by Common Destination
,: Carrier
;< ❑Disinterment
Date Cemetery Address
Reinterrnent Data Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Donaldson Funeral Home 00473
Address
'. 100 N Maln Si,Messena,Now York 13862
' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, if Other than Above
Address
of
:u
Permission is hereby granted to dispose of the human remains described above as Indicated.
'`;a Date Issued 02/26/2018 Registrar of Vital Statistics 4ppbertjt Curtis(Ztectronicarfx ipnart) _
( ►► )
'" District Number Place
6601 Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition Z/Z$1i9 Place of Disposition ���� �+ 1a f,r,
( ► )
(section) (lot numb (grave number)
Name of Sexton or Person In Charge of Pr mises ( "wtpL
7 fN.ase pint)
Signature di lr^� Title ft
(over)
DOH-1555(02/2004)
a
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
is Name First Middle Last Sex
Edith L.Baker Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/22/2018 99 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
3 Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Kenneth France MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 104
. '..❑Burial Date Cemetery or Crematory
02/26/2018 Pine View Crematory
El Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
El Transportation Shipment
:—:,; by Common Destination
' Carrier
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Donaldson Funeral Home 00473
1. Address
• 100 N Main St,Massena,New York 13662
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 02/26/2018 Registrar of Vital Statistics ,R9tiertA Curtis(Electronically Signed)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Place of Disposition
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
-- Signature Title
(over)
DOH-1555 (02/2004)