Cullen, Mary tX llL
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Mary M. Cullen Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 24, 2011 74 War or Dates
la. Place of Death Hospital, Institutior1irondack Tri-County Health Care
`Z City, Town or Village Johnsburg Street Address Center
p; Manner of Death X Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
u] Circumstances Investigation
W, Medical Certifier Name Title
O Dr.Dean Reali
Address
HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 /7
❑Burial Date Cemetery or Crematory
April 26,2011 Pine View Crematory
Ill Entombment
Address
❑x Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
u)
0 —
Date Point of
coTransportation 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 00035
Address
3809 Main Street, Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
X Address
W,
O.
Permission is hereby granted to dispose of the human remain desc ibed a ovp ndicated.
l �,� Ceti
Date Issued ��02 SIo2U)/Registrar of Vital Statistics
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition `I/'7 i Place of Disposition "( int� ,;&./ C door ,...
a (address)
W
co
ce
(section) (lot numb (grave number)
Q Name of Sexton or Person in Charge of Premises ?Ai-,i�"�Z (please print)
W 4115fit.a_Signature Title (@Cm Arot
(over)
DOH-1555 (02/2004)