West, Arlene ItZ.l
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arlene West Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 23,2011 63 War or Dates
Place of Death Hospital, Institution or
'Z City, Town or Village Minerva i Street Address 11 Lake View Road
Manner of Death 'g�Natural Cause I I Accident Homicide [ 1 Suicide [ I Undetermined Pending
to Circumstances Investigation
U
W Medical Certifier Name Title
O Daniel Way
Address
H1H3N,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City, Town or Village Minerva 1 1557 1 1
❑Burial Date Cemetery or Crematory
II]Entombment May 24,2011 , Pine View Crematory
Address
LI Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
z I 1 Removal and/or Held
and/or Address
F' Hold
U)
O Date Point of
N Transportation j Shipment
a by Common Destination
Carrier
Disinterment Date I Cemetery Address
-I Reinterment Date , Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
E Address
CC
W
b" Permission is hereby granted to dispose of the human mains described above as indicated.
Date Issued 14 1 t Registrar of Vital Statistics - --'k-a� Y � 61—
(signature)
District Number 1557 Place Minerva
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition 6 /26/fi' Place of Disposition ite�trLd C..e►..itvfav,.
(address)
W
Cl)
0 (section) 41 _t (lot limber) (grave number)
O Lti Name of Sexton or P r on in Char a of Premises r,s}�WVr =„+v/t
� _II
W (please print)
Signature �` , Title CI
Mt4 c�
/ (over)
DOH-1555 (02/2004)