Madden, Gracia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gracia Lee Madden Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 10,2014 64 War or Dates
t- Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 15 Iroquois Trail
pManner of Death n Natural Cause Accident n Homicide n Suicide fl Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Jennifer Donovan
Address
HHIHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register nNumber
City, Town or Village litssitegohnsburg 12/05655 1
El Burial Date Cemetery or Crematory
February 12,2014 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZO H Removal and/or Held
and/or Address
�' Hold
O Date Point of
Nn 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
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
Address
0-. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued og-- )1- c) 0)1A Registrar of Vital Statistic 2 . C
(signature)
District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition Place of Disposition "Et�,�+w ( tchc�dw..
(address)
Co
CC (section) dIbt
(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises 3/1nll}( se print)
W Signature s„ Title G ►MI-
(over)
DOH-1555 (02/2004)