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Virgil, Sophiannah A gs3 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sophiannah G. Virgil Female Date of Death Age If Veteran of U.S. Armed Forces, November 26,2016 0 War or Dates p.,, Place of Death Hospital, Institution or Z City, Town or Village Johnsburg Street Address 454 Goodman Road pManner of Death X Natural Cause Accident ( I Homicide Suicide Undetermined Pending W Circumstances Investigation tut, Medical Certifier Name Title Address Death Certificate Filed District Number Register Number City, Town or Village Johnsburg 5655 3 ❑Burial Date Cemetery or Crematory r Entombment November 29,2016 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address E Hold N 0 Date Point of a. N Transportation 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 I-. Remains are Shipped, If Other than Above '2 Address l 0 'Th Permission is hereby granted to dispose of the human r mails de i d a e as indicat Date Issued 1 ( -cA-1 Registrar of Vital Statistics • % /6 ign ure) District Number Place �. � h.t I certify that the remains of the decedent identified above were disposed of in accordance with , i permit on: Z • WW Date of Disposition IZl I IR, Place of Disposition eniV1?,,) C o,w W (address) Cl) re 0 (section) /�(lot number) e (grave number) p Name of Sexton or Person in Charge of Premises (/ „Si r rNo1/li— Z (plAase print) W Signature /i Title (REiht1 t (over) DOH-1555 (02/2004)