Menshausen, Nathalie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nathalie L. Menshausen Female
' Date of Death Age If Veteran of U.S. Armed Forces,
November 3,2015 104 War or Dates
; -tPlace of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Wesley Health Care Center,Inc
Manner of Death I XI Natural Cause I l Accident I J Homicide Suicide Undetermined Pending
` ` Circumstances Investigation
Medical Certifier Name Title
retf Rick Teetz
Address
131 Lawrence St.,Saratoga Springs,NY 12866
Death Certificate Filed District Number Register Number
.:: City, Town or Village 11 b I
❑Burial Date Cemetery or Crematory
❑Entombment November 4,2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
Cl)
O Date Point of
NTransportation 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
Remains are Shipped, If Other than Above
Address
liJ
iCL Permission is hereby granted to dispose of the human re es ibe o s indic ted.
Date Issued €il /
Q f s Registrar of Vital Statistics e •
°�,; (signature)
, District Number u 5 ) 1 Place e../t) 6 1 L Spd 1 s
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
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P /
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• Date of Disposition It I Or Place of Disposition roues C 4..—
W (address)
tY (section) (lot numbed (grave number)
pName of Sexton or Person in Charge of Premises aus ' t+air
Za (please print)
W /�Signature L/v Title (M wt'j,
(over)
DOH-1555 (02/2004)