Pellerin, Marion NEW YORK STATE DEPARTMENT OF HEALTH
t ti � 10
Vital Records Section Burial - Transit Permit
_ , Name First Middle Last Sex
, Marion G. Pellerin Female
;.*ff Date of Death Age If Veteran of U.S. Armed Forces,
` = September 28,2014 90 War or Dates
-4:4. Place of Death Hospital, Institution ltirondack Tri-County Health Care
Z: City, Town or Village Johnsburg Street Address Center
la
la Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
la Circumstances Investigation
la Medical Certifier Name Title
Thomas Warrington
.::* Address
: HUHN,Johnsburg,NY 12843
-;, Death Certificate Filed District Number Register N�jmber
. City, Town or Village Johnsburg 5655 0� l ,
❑Burial Date Cemetery or Crematory
October 1,2014 Pine View Crematory
❑Entombment Address
N Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
H Hold
N
O Date Point of
n Transportation 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
x:r 3809 Main Street,Warrensburg,NY 12885
. Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
a Address
lY-
W.
1:
%- Permission is hereby granted to dispose of the human re ins describe above i icated.
F
_' Date Issued IC)-1_ Registrar of Vital Statistics b CI, d
"F
(signatur )
ga= District Number 5655 Place Johnsburg
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition IC./l( y Place of Disposition Zap R
(address)
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W
U)
0 (section) lot number) (grave number)
p0 Name of Sexton or Person in Charge of Premises itrJ_, sr,,,,4-
Z (plealse print)
W
Signature t�`� Title
(over)
DOH-1555(02/2004)
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