Teachout, Shellie Tr
NEW YORK STATE DEPARTMENT OF HEALTH • . it, 1.3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shellie M. Teachout Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 28,2011 51 War or Dates
:g' Place of Death Hospital, Institution or
City, Town or Village Johnsburg Street Address 500 Hudson Street
p Manner of Death X Natural Cause n Accident I 'Homicide Suicide 1 Undetermined Pending
U Circumstances Investigation
la Medical Certifier Name Title
Mark M.Hoffman
Address
420 Glen Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Num er
City, Town or Village T/O Johnsburg 5655 /
❑Burial Date Cemetery or Crematory
Enter /
t ) Zo(( Pine View Crematory
Address
®Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
F' Hold
cn
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Date Cemetery Address
n Disinterment
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
M, Remains are Shipped, If Other than Above
Address
a.
Permission is hereby granted to dispose of the human rei cribed ab as indicated.
Date Issued 2 Registrar of Vital Statistics C�/ �s -if ed, C�C„
(signature)
:` District Number 5655 Place T/O Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z i, /`
ui LU u Vti Date of Disposition 4-4-11 Place of Disposition ,• i� t orwL
W (address)
U)
O (section) a , (lot number) (grave number)
pName of Sexton or Pefson in Char of Premises r.1°- i.- .... onAllt
z (please print)
W Signature _ Title CITE./h Yc10a
(over)
DOH-1555 (02/2004)