Dupuis, Nancy NEW YORK STATE DEPARTMENT OF HEALTH •$ _(`II
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy C. Dupuis Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 29,2015 71 War or Dates
Place of Death Hospital, Institutiorl1irondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
James Hindson Dr.
Address
''Main St.,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
: City, Town or Village 5655
❑Burial Date Cemetery or Crematory
June 1,2015 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier _
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
=" Permit Issued to Registration Number
m 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
i44.1 Remains are Shipped, If Other than Above
7i Address
ILI
Permission is hereby granted to dispose of the human re ins described bove as in ' ated.
Date Issued 6-).. ( 5 Registrar of Vital Statistics t9 q , �
(signature)
District Number 5655 Place Johnsburg
F-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /-
LU Date of Disposition t/3//3' Place of Disposition MCI..., C,r . M.o..,.-tor� ,
Ili (address)
N
0 (section) (lot number) (grave number)
ZZ Name of Sexton or Person in Charge of Premises A,*fit Sat f
(pl ase print)
Ili
Signature 44--- Title /n ttRtl
(over)
DOH-1555 (02/2004)
r..
Hold 0 Date Point of
N❑Transportation Shipment
L1 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
: Permit Issued to Registration Number
-i Name of Funeral Home figtoni \ . RX}r F3�,rj ML
Address
„„: N C.i'WO.1-y4,-71-6- Cr. 01)66--AS 6 0 ay Ay 12.4r--65(
Lis Name of Funeral Fjihm Making Disposition or to Whom l
Remains are Shipped, If Other than Above
Address
Z
3F
: Permission is hereby granted to dispose of the human remains described above as indicated.
`'> " .t-�t -'t. J`}�
. <: Date Issued 3/ 2S'/J;5' Registrar of Vital Statistics V C