Watkins, Della NEW YORK STATE DEPARTMENT OF HEALTH �0
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
1 Della May Watkins Female
t1.4 Date of Death Age If Veteran of U.S. Armed Forces,
12/12/2017 96 Years War or Dates
`' Place of Death Hospital, Institution or
City, Town or Village Johnsburg Town Street Address Adirondack Tri-County Nursing And Rehabilitation Center, I
Manner of DeathRAJ Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Warrington PA
Address
<? 112 Ski Bowl Rd,Johnsburg Town,New York 12853
„a Death Certificate Filed ' District Number Register Number
Ai City, Town or Village North Creek 5655 34
x
,If_ Li Burial Date Cemetery or Crematory
12/14/2017 Pine View Crematory
�, ❑Entombment Address
®Cremation Queensbury Town, New York
Date \ Place Removed
❑Removal and/or Held
and/or Address �—
Hold
Date �— Point of
❑Transportation _ Shipment
by Common Destination —
n " Carrier
❑Disinterment
Date =— Cemetery Address
El Reinterment Date Cemetery Address
i
., Permit Issued to Registration Number
Avo
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
.rt 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 12/14/2017 Registrar of Vital Statistics 1oASmith Ekctronicali5sis+ed'
(signature)
4 District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition It(10 1) Place of Disposition f:uil (' �
(address)
(section) / lot number) (grave number)
Name of Sexton or Person in Charge of Premises G .riot_ SA-0(
M A a� (plehse print)
Signature �'l Title atnK-
(over)
DOH-1555 (02/2004)