Cole, Lucy NEW YORK STATE DEPARTMENT OF HEALTH # 5-5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lucy M. Cole Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 6,2011 98 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Care Facility
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
s Circumstances Investigation
#11 Medical Certifier Name _ Title
Bernardo R.Villajuan
Address
88 Broad St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 /.9'D
❑Burial Date Cemetery or Crematory
November 7,2011 Pine View Crematory
❑Entombment Address
®Cremation Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
co
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
1 Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
Address
It
.U,
Permission is hereby granted to dispose of the human mains described abov as indicated.
a Date Issued 1\ - ) -�. 1-1 Registrar of Vital Statistics \
turej qb
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z LIJ Date of Disposition Nov.`ir, Zw )�
1 Place of Disposition tile,' Clef ort,_
(address)
W
N
re (section) (lot numf ter) (grave number)
QName of Sexton or Perso in Charge of Premises I krtstopier J ev,ati
ZAO (please print)
W Signature Title C e.M}i-16(L
(over)
DOH-1555 (02/2004)