Arnold, Rita A
NEW YORK STATE DEPARTMENT OF HEALTH --nr
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
Rita Ann Arnold Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 21,2016 69 War or Dates
Place of Death Hospital, InstitutioriAcd'irondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
Manner of Death g Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
u Medical Certifier Name Title
a° James Hindson MD
Address
Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 3
❑Burial Date Cemetery or Crematory •
Entombment October 24,2016 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N l 'Transportation Shipment
a 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 00037
Address
3809 Main Street,Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
: Remains are Shipped, If Other than Above
Address
s' Permission is hereby granted to dispose of the human remains descr bed abov: a 'ndicated.
�0-)L4- 1 'U, Registrar /
Date Issued of Vital Statistics �`�� � � "�
(sign.•Ore)
District Number (1) Place '.L7 ,>\,
I certify that the remains of the decedent identified above were disposed of in accordanc ith this permit on:
W Date of Disposition /Di Zb/ib Place of Disposition .rneOW,„J Lrvw`. cx,w-
W (address)
U)
W (section) jj Plot number)r_ (grave number)
pName of Sexton or Person in Charge of Premises (Ir,s •31141I f
Z (p ase print)
W
Signature / Title MC ri OK
(over)
DOH-1555 (02/2004)