Langworthy, Christine I
44 3.6J.
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Christine A. Langworthy Female
Date of Death Age ' If Veteran of U.S. Armed Forces,
August 3,2011 60 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg j Street Address One Smith Street
p Manner of Death Natural Cause I !Accident Homicide X Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Timothy E.Murphy Mr
Address
52 Haveland Ave.,Glens Falls,NY 12801
Death Certificate Filed District Number 1 Register Number
City, Town or Village Warrensburg 5660
❑Burial Date Cemetery or Crematory
August 5,2011 Pine View Crematory
D Entombment Address
El Cremation Quaker Rd.,Queensbu y,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
O Date Point of
NTransportation Shipment
a 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 _I 00835
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
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W
a
Permission is her y ranted to dispose of the human - . : .escribed ove/as indicated.
Date Issued c� S / Registrar of Vital Statisti = ���>'j . Lihnh-____
-9
(signature)
District Number 5660 Place Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z •
it! Date of Disposition 1- -(( Place of Disposition t+u UIt..) Ciro..t on,t
M (address)
W
co
0 (section) /� . ((ot number) (grave number)
pName of Sexton or erson in Char of Premises L 'Ir•�' htr' JtoA.Lif
Z D ►(please print)
w iki'Lk a11i.1�7 .,
Signature (�/� Title ✓
v
(over)
DOH-1555 (02/2004)