Pelletier, Ione NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ione M. Pelletier Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 4, 2011 93 War or Dates
Place of Death Hospital, Institution 1irondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
G� Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
tit Circumstances Investigation
uji Medical Certifier Name Title
Thomas Warrington PA
Address
HHHN,North Creek,NY 12853
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 ON.
❑Burial Date Cemetery or Crematory
January 5,2011 Pine View Crematory
0 Entombment Address
®Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
co
0 Date Point of
N I I Transportation 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
#;F Remains are Shipped, If Other than Above
2 Address
ct
Wa
a.
Permission is hereby granted to dispose of the human rem ins described ae as indicated.
Date Issued di/os Jao i Registrar of Vital Statistics ,_AJ212 - ' C2tx$2�.
(signature)
J
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition �,jc,.t,i MO Place of Disposition -r�77 itt0if,., Cr/nttuf,�
(address)
w
co
tY (section) 4 (�1 ``''umber) (grave number)
pName of Sexton or 7 son in Char of Premises t. 1,/,,Alkir Jo"^eif
Z (please print)
W Signature Title CQ,r lif A.-to.,
(over)
DOH-1555 (02/2004)