West, Clara rt 6 L/3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ) Burial - Transit Permit
Name First Middle Last Sex
Clara B. West Female
=°! Date of Death Age If Veteran of U.S. Armed Forces,
j October 6,2014 98 War or Dates
Place of Death Hospital, Institutiorirondack Trii-County Health Care
City, Town or Village Johnsburg Street Address Center
Manner of Death X Natural Cause Accident I I 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 T/O Johnsburg 5655 Q 9
❑Burial Date Cemetery or Crematory
Entombment October 10,2014 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
O Date Point of
NTransportation 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
s , Remains are Shipped, If Other than Above
Address
M�`' Permission is hereby granted to dispose of the human remains described above as 'ndicated.
Date Issued 10I ) 1q Registrar of Vital Statistics p Q.s
(signature)
District Number 5655 Place T/O Johnsburg
F I certify that the remains of the decedent identified above we e disposed of in accordance with this permit on:
Z f
W Date of Disposition`1 /QIl Place of Disposition //1/ /r,) U41iT)4y'
W (address)
CO f
O (section) (lot ou ber) / (grave number)
pName of Sexton P Charge of Premises i-it.) T /I cJ
Z (pleas print)
IL
Signatur 1 Title -,yf„rtiC7'
(over)
DOH-1555 (02/2004)