Hitchcock, Rebecca NEW YORK STATE DEPARTMENT OF HEALTH # 7-7 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rebecca A. Hitchcock Female
Date of Death Age If Veteran of U.S.Armed Forces,
May 25,2012 62 War or Dates
i„_ Place of Death Hospital, Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
aManner of Death['Natural Cause Accident Homicide Suicide Undetermined x Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica ME
Address
50 Broad St.,Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 2.1-1.7
❑Burial Date Cemetery or Crematory
May 30,2012 Pine View Crematory
Address
D Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z
( {Removal and/or Held
and/or Address
E Hold
O Date Point of
N I I 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 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
d Address
W ,
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05-30-12 Registrar of Vital Statistics W Cu.y' Vv
(signature
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
na Date of Disposition j 130lit Place of Disposition ,P..sUu- C. oriv.,-
w (address)
W
U)
W (section) (lot number) (grave number)
pName of Sexton or Person in Charge f Premises tkr,It r cN44
Z / (Please Print)
w /%Signature L_ Title Ci) t A,O(1-
(over)
DOH-1555 (02/2004)