Maxam, Louise NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section t . * Burial - Transit Permit
Name First Middle Last Sex
Louise A. Maxam Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 26,2010 73 War or Dates
F- Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address 275 Pyramid Pines Estates, Saratoga
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Thomas Salvadore Coroner
Address
41 So.Main St.,Mechanicville,NY 12118
Death Certificate Filed District Number 4.(5-6 Q Register Number
City, Town or Village T/O Wilton,NY T/O Wilton,NY / u/y.
❑Burial Date Cemetery or Crematory
December 31,2010 Pine View Crematory
❑Entombment Address
IN Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
and/or
i— Hold Address
N
O Date Point of
a Shipment
to Transportation Shi P
o by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Alexander-Baker Funeral Home Registratio0ber
Name of Funeral Home
Address 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
IY
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12-28-10 Registrar of Vital Statistics
( Ognature)
District Number Y.SZ1 Place T/O Wilton,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition .?q, ill200 Place of Disposition "Pine 0,f..-, Cam,.41 or,,,..
W (address)
Cl)
O (section) /I (lop'mber) (grave number)
00 Name of Sexton or Person in Charge o Premises C hr,siuehet ct.,,wft
Z A j (please print)
W Signature (Mk. Title CA IMA-TU¢—
(over)
nnN.i ccc rn7i nna1