Baker, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle ' Last Sex
Evelyn Norma Baker I Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 25, 2015 76 War or Dates
1= Place of Death Hospital, Institution or
al City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death LurnNatural Cause 0 Accident ❑ Homicide Suicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
A�i y6Ctgn
Address
l02 Erd d, 5 6/eves gt Ili
Death Certificate Filed District Number Regist Num r
ov City, Town or Village ,.5-‘Q/ 7V
❑Burial Date Cemetery or Crematory
July 28, 2015 Pine View Crematorium
❑Entombment Address
:`®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
zriRemoval and/or Held
and/or Address
EHold Pine View Crematorium
CO Date Point of
f�L 0 Transportation Shipment
(t) by Common Destination
CI Carrier
Disinterment Date Cemetery Address
0 Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
IL Remains are Shipped, If Other than Above
2 Address
I
W!
13. Permission is hereby granted to dispose of the human remains described above as indic ted.
Date Issued ) /2. , / 15 Registrar of Vital Statistics WCAA.3/4-1/42_.
(signature)
District Number .560 ) Place 6 152. -S o k\$ ,ti ki
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i. irtet' i..J �+¢,,.a.(r �
tih Date of Disposition 07/28/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 7-3/-Jags (address)
WCO
IX (section) (lot number) (grave number)
Name of Sexton or Person in Charge f Premises f `"-'° '�'�'�`elk
✓� (please print)
Ui Signature ��-,raw Title Cr< er7 Oirc4 r
(over)
DOH-1555 (02/2004)