Watson, Ruth NEW YORK STATE DEPARTMENT OF HEALTH S
Vital Records Section z Burial - Transit Permit
Name First Middle Last Sex
Ruth Vivian Watson Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/25/2011 92 years War or Dates
Place of Death Hospital, Institution or
City, Towygo/ilX Glens Falls Street Address Glens Falls Hospital
Manner of Death❑platural Cause El Accident El Homicide Q Suicide r iUndetermined ri Pending
Circumstances Investigation
0.
la Medical Certifier Name Title
14 Gamal Garhy Khalifu M D
Address
100 Park Street Glens Falls, N Y
Death Certificate Filed District Number Register Number
City, Tow X/iI XX Glens Falls 5601 510
gi❑Burial Date Cemetery or Crematory
QEntombment 11/28/2011 Pine View Cemetery
Address
11❑Cremation • Queensbury, NY 12804
Date Place Removed
Removal and/or Held
and/or Address
CA h Hold
O Date Point of
Transportation Shipment
O by Common Destination
iiiii Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to- Registration Number
ini 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
i
in
P' Permission is hereby granted to dispose of the human remains descr' ed above s in t d.
Date Issued 11/28/2011 Registrar of Vital Statistics d , -e
gi signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iLi Date of Disposition a 1 t Ida Place of Disposition -at(btu) avr p t ice.
(address)
Ili
Ul
CC (section) / . (lot numbery (grave number)
Name of Sexton or Person in Charge Premises r0'4 r Se hiR
2 iii
ATLI.-
(please print)
!iiiiRSignature Title etEmllt (4_
(over)
DOH-1555 (02/2004)