Wallace, Frances 225
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frances Wallace Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 19,2017 91 War or Dates
4,.. Place of Death Hospital, Institution or
3City, Town or Village Glens Falls Street Address Glens Falls Hospital
: Manner of Death Undetermined Pending
X Natural Cause Accident Homicide Suicide
Circumstances Investigation
W; Medical Certifier Name Title
9 Suzanne Rayeski
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls - 5601 17Z.
❑Burial Date Cemetery or Crematory
March 21,2017 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
NTransportation 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
e , Remains are Shipped, If Other than Above
Address
;, Permission is hereby granted to dispose of the human remains described above a€ indicated.
Date Issued 3 / .o I/ 7 Registrar of Vital Statistics W C+vVI-v-e .A-"IWI
(signature)
District Number 5 6o 1 Place C L9./\A3 �-J,_\S �N '7'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition 3 2///7 Place of Disposition J )?7au 3L.,) Cr -nl '4
W / (address)
co
re
0 (section) 1 ,(lot number) (grave number)
Op Name of Sexton or P son i Charge of Premises J t--1 i G-v1 , LCc,ci.e
Z (please print)
W Signature Title G✓'2yftc--gyp
(over)
DOH-1555 (02/2004)