VanKeuren, Alyce NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alyce H. Van Keuren Female
Date of Death Ag a 1 If Veteran of U.S. Armed Forces,
March 26,2014 71 I War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
tp Manner of Death I XI Natural Cause Accident [ Homicide Suicide Undetermined Pending
Circumstances Investigation
uj G Medical Certifier Name Title
Paul Bachman
Address -
HHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls �5601 tl 5 5
❑Burial Date Cemetery or Crematory
❑Entombment March 28,2014 Pine View Crematory
Address
Lx Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
0 Date Point of
N Transportation Shipment
a 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 0003 7_
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
W
• Permission is hereby granted to dispose of the human remains described above,as indicated.
Date Issued .3/ 2.5i I ft-i Registrar of Vital Statistics w C.,...1-y \A).
(signet 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 •NI31IM Place of Disposition ati C-ctot�
W (address)
f/)
(section) _ (lot number) (grave number)
p Name of Sexton or Perso in Char a of Premises2 J(�,
Z (please p "nt)
W
Signature Title ►C
(over)
DOH-1555 (02/2004)