Fish, Helen NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit (o
Vital Records Section ttill
' ' Name First Middle Last Sex
Helen G. Fish Female
Date of Death Age If Veteran of U.S. Armed Forces,
` December 28,2011 92 War or Dates
, . Place of Death Hospital, Institutioriltke Stanton Nursing & Rehabilitation
: City, Town or Village Queensbury
1Street Address Centre
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
per Medical Certifier Name Title
Roslyn Socolof
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
: City, Town or Village Queensbury 5657 / a
❑Burial Date Cemetery or Crematory
December 29,2011 Pine View Crematory
III Ent°mbillent Address ,
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
'`A Name of Funeral Home Alexander-Baker Funeral Home 00035 _ __
Address
'1 3809 Main Street,Warrensburg,NY 12885
' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
: Address '
tit
Permission is hereby granted to dispose of the human r mains described above as indicated.
Date Issued V3-' a� Registrar of Vital Statistics `� y);�=`_ Cl , ,_
_________
(signature)
a, District Number 5657 Place Queensbury '
I certify that the remains of the decedent identified above were disp sed of in accordance with this permit on:
ui Date of Disposition RN Hi ZAZ Place of Disposition ,n U,..i 6rvh*ctor i,-
W (address)
co
re (section) - (lot numb r) (grave number)
ZZ Name of Sexton or Person in Charge,•f Premises C r,i � 2hN144-
L (please print)
iii
Signature 711 Title (RE rnf-zb1_,
(over)
,DOH-1555 (02/2004)