VanGuilder, Anna NEW YORK STATE DEPARTMENT OF HEALT I L I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anna D. VanGuilder Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 13,2016 69 War or Dates
1.1. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause I I Accident Homicide Suicide 1 I Undetermined Pending
t13 Circumstances Investigation
w Medical Certifier Name Title
O John Stoutenberg
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 17 53
❑Burial Date Cemetery or Crematory
February Lmb-- Pine View Crematory
Ell Entombment Address
®Cremation 21 Quaker , J., Quee, 'iry, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment 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
1, Remains are Shipped, If Other than Above
Address
LU
A.
Permission is hereby granted to dispose of the human remains described� above as indicated.
Date Issued 21 I b ) 16 Registrar of Vital Statistics Ck. " 1 'be
(signature
District Number 5601 Place Glens Falls) hi kil
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WI— r (ro`
Date of Disposition Z iJ(.iiF Place of Disposition sae illl�:,,, t W+-
2 (address)
W
U)
CC (section) at (lot number) (grave number)
pName of Sexton or Person in Charge of Premise 3�i'
Z 7 (p ase print)
w Signature f {f-- Title CkArti5t.
(over)
DOH-1555 (02/2004)