Weller, Justeen NEW YORK STATE DEPARTMENT OF HEALTH Or
Vital Records Section Burial - Transit Permit
iS Name First Middle Last Sex
Justeen Marie Weller Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/11/7011 80 years War or Dates
14: P ce of Death Hospital, Institution or
Ci Tow /i s�.� Glens Falb Street Address park St Glens Falls, N Y
ner of Death CAI Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
Mathew Varughese M n
Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
CI ow idiIXX Glens Falls 5601 268
urial Date Cemetery or Crematory
❑Entombment 06/13/2011 Pine View Crematory
Address
iiiill OCiemation Queensbury, NY
Date Place Removed
❑Removal and/or Held
wooi and/or Address
Ill Hold
0 Date Point of
chilL L.jr-1 Transportation Shipment
25 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
: Permit Issued to Registration Number
s: Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
lu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/13/2011 Registrar of Vital Statistics W CA-
(signature)
District Number 5601 Place Glens Falls /// / /02,c0/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition r,-tt,lk-lt Place of Disposition -Pillow, `i nq{oPlu,n.
(address)
ILI
ll
fr (section) (lot numbe (grave number)
0
CI Name of Sexton or Per n in Charge Premises do:4 r Aittii-
Z
(please print)
10
Signature L. Title CCEVIIRTC--
(over)
DOH-1555 (02/2004)