Wurzbach, Nellie NEW YORK STATE DEPARTMENT OF HEALTH i - Trans 'Permit
Vital Records Section Burial
` Name First Middle Last Sex
Nellie M. Wurzbach Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 28,2012 104 War or Dates
, Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Care Facility
Manner of Death Undetermined Pending
e ° X Natural Cause Accident Homicide Suicide
Circumstances Investigation
r Medical Certifier Name Title
Roslyn Socolof MD
Address
14 Manor Drive,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queesnbury 5657 42(V
❑Burial Date Cemetery or Crematory
September 28,2012 Pine View Crematory
II Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
O Date Point of
N I I Transportation 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
rsY Name of Funeral Firm Making Disposition or to Whom
L•, Remains are Shipped, If Other than Above
E Address
le
to
• Permission is hereby granted to dispose of the human r mains described ab e as indicated.
Date Issued 1,_ -3c.r z Registrar of Vital Statistics Llil,tr-Ce 14\
(signatu )
District Number 5657 Place Queesnbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition to-i-17. Place of Disposition 7,,.tato C.t+.elo1. -..
2 (address)
W
O (section) (lot numb (grave number)
0p Name of Sexton or Person in Charge f Premises r+3 ...Wit
ZA (please print)
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Signature Title C> t.rh14'r
(over)
DOH-1555 (02/2004)