Coulman, Avah t rill
W YORK STATE DEPARTMENT OF HEALTH
tal Records Section Burial - Transit Permit
,' Name First Middle Last Sex
z=. Avah Ray Coulman Female
1:1a Date of Death Age If Veteran of U.S. Armed Forces,
February 13,2011 2 War or Dates
lit
Is
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
Cause Accident Homicide Suicide ` X
Circumstances Investigation
`w Medical Certifier Name Title
Paul Bachman
Address
HHHN,Warrensburg,NY 12885
, Death Certificate Filed District Number Register umber
City, Town or Village Glens Falls 56413
❑Burial Date Cemetery or Crematory
February 15,2011 Pine View Crematory
El Ent°mbment Address
0 Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
y Transportation Shipment
p by Common Destination
Carrier
]Disinterment Date Cemetery Address
ri 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
Remains are Shipped, If Other than Above
Si Address
tit;
"] Permission is hereby grantedto dispose of the human remains descr''/ed a ove s in d.
a Date Issued e2 /5 2D// Registrar of Vital Statistics i2 � �
/ g ,�
(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:
Z
Lu Date of Disposition Peil (b 1204 Place of Disposition Pvi, li lit., (ou f-orw.N..
W (address)
U)
re (section) (lot numb (grave number)
pName of Sexton or Perso in Charge of P mises 41,S ) r+ 0114/�
Z (please print)
W
Signature71 Title rnePhi*L
(over)
DOH-1555(02/2004)