Black, Sheila NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sheila S. Black Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 2,2015 54 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
to Medical Certifier Name Title
0 Daniel Sooriabalan
Address
HHFIN
Death Certificate Filed District Number Register Number
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
El
Entombment October 5,2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804 _
Date Place Removed
Z Removal and/or Held
52 and/or Address
Hold
N
O I Date Point of
cnTransportation _ 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 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CL
Permission is hereby granted to dispose of the human remains described above as
indicated.di
Date Issued 2 t2 j 15 Registrar of Vital Statistics W c,w C�.����
(signat re)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition jOIG(;dS Place of Disposition p,A.V, ) c,ce.►"1�c)r)u✓h(address)
N
cc (section) n (lot number (grave number)
pName of Sexton or Person in Char of Premises giro number)._
(f lease print)
w Signature (/ Title 1-17*"0i2
(over)
DOH-1555 (02/2004)