Randall, Timothy # lit
NEW YORK STATE DEPARTMENT OF HEALTH , .
Vital Records Section Burial - Transit Permit
-v u_ Name First Middle Last Sex
Timothy A. Randall Male
¢AT,
-: Date of Death Age If Veteran of U.S. Armed Forces,
`=s°` April 1,2011 62 War or Dates
` Place of Death Hospital, Institution or
Qa
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ' Natural Cause Accident I I Homicide n Suicide Undetermined Pending
Ill Circumstances Investigation
tit Medical Certifier Name Title
: John Stoutenberg
Address
Ear, 102 Park Street,Glens Falls,NY 12801
tsc Death Certificate Filed District Number Register Number
,, City, Town or Village Glens Falls 5601 �L' j
❑Burial Date Cemetery or Crematory
April 4,2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NU Transportation Shipment
p by Common Destination
_ Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
_--'', Permit Issued to Registration Number
:1:., Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
a 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tht Permission is her by granted to dispose of the huma remains described aboveov as i dicat d.
Date Issued Q// Registrar of Vital Statistics �.Q�_�`.� J C2/`.C._.
(signature)
Fg x; District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above ere disposed of in accordance with this permit on:
W Date of Disposition L) L-11 Place of Disposition Pik.,U,,�, CainAt 0 tOf�a (address)
W
CO
Ce (section) (lot num ) (grave number)
Op Name of Sexton or Per on in Charge of Premises a,r,sigi e ntw(t
Z I (please print)
W Signature t1 /La_._ Title C115hI1}1 O1<-
I
(over)
DOH-1555 (02/2004)