Latham, Virginia NEW YORK STATE DEPARTMENT OF HEALTH n�#
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia S. Latham Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 27,2017 71 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address One Jay Street,Apt. 7D
flManner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
W.0Circumstances Investigation
i9 Medical Certifier Name Title
Robert Evens
Address
One Iron Gate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register(V 1pr
City, Town or Village Glens Falls 5601 '
❑Burial Date Cemetery or Crematory
Entombment Address
1,2017 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
H Hold
co
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
Remains are Shipped, If Other than Above
°S. Address
Ma
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/1 117 Registrar of Vital Statistics (jk-)c_1't1-1 ..J w.,..A.f_cet_..,
(signatur
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 3)z111 Place of Disposition fjqi, ate' (,,y„,.p0,�..,
W (address)
U
ct (section) jpotL.number) (grave number)
p Name of Sexton or Person in Charge of Premises ��r �
Z (pl4ase print)
iu
Signature 4. 4 Title (PEinKIbit
(over)
DOH-1555 (02/2004)