Williams, Gloria IF
NEW YORK STATE DEPARTMENT OF HEALTH 3--7U
Vital Records Section Burial - Transit Permit
Si Name First -Middle Last Sex
Gloria Jean Williams Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/21/2011 81 years War or Dates
P ..- of Death Hospital, Institution or
a ! ow1StrAllitgAXX Glens Falls Street Address Park St Glens Falls, N Y
•f r of Death IN"'I Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. 4� Circumstances Investigation
tu Medical Certifier Name Title
o Paul Bachman Coroner
Address
Warrensburg Health Center, Warensburg, NY
;;' --. h Certificate Filed District Number Register Number
!!?ic Ci owix II X Glens Falls 5601 331
i i =urial Date Cemetery or Crematory
❑Entombment 07/25/2011 Fine View Crematory
DRiilFCc,emation Queensbury, NY
Date Place Removed
- ❑Removal and/or Held
and/or Address
w Hold
0 Date Point of
0t'0 Transportation Shipment
Ls by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
'': Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
2
Ilia
CIL
Permission is hereby granted to dispose of the human remains descri e/d above s in ' t d.
Date Issued 07/25/2011 Registrar of Vital Statistics o '
mi (signature)
District Number 5601 Place Glens Falls /A7,V /2 /
iiiiii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 I Date of Disposition 7 IlL I q Place of Disposition Pme Va.) Cr�.chctun.
2 (address)
ili
W.
LC (section) got numbere (grave number)
�c»�
il3 Name of Sexton or Person in Char e of Premises �" e��if
(please print)
ta Signature (14114L—
:::::::::: Title (Ate)v i,Oft
(over)
DOH-1555 (02/2004)