Russell, Sybil NEW YORK STATE DEPARTMENT OF HEALTH t -
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sybil A. Russell Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 23,2011 62 War or Dates
1.,. Place of Death Hospital, Institution or
Z City, Town or Village Glens FallsILI Street Address Glens Falls Hospital
0 Manner of Death I X{Natural Cause Accident Homicide ' i Suicide I `Undetermined [ Pending
ILI
Circumstances Investigation
w Medical Certifier Name Title
G Suzanne Rayeski MD
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 �. 2.
❑Burial Date Cemetery or Crematory
June 27,2011 Pine View Crematory
lil Entombment Address
Ill Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z ( 'Removal and/or Held
and/or Address
H Hold
co
O Date Point of
55 1 'Transportation Shipment
p by Common Destination
Carrier
' 'Disinterment Date Cemetery Address
`Renterment 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
H Remains are Shipped, If Other than Above
E Address
CC
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0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6-24-2011 Registrar of Vital Statistics L CA-A- -v'`Q
(signatu )
District Number 5601 Place Glens Falls,NY
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 6/fl III Place of Disposition e,trty`U rw•ate+,.,,
2 (address)
W
N
CL
(section) (l9t-n umber) (grave number)
Op Name of Sexton or Per on in Charg of Premises Aft-. ki^ - toot-1
z (please print)
LU Title CVl►l�-
Signature ApL.
(over)
DOH-1555 (02/2004)