Fosmer, Elinor NEW YORK STATE DEPARTMENT OF HEALTH JJJ
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Elinor Fosmer Female;
Date of Death Age If Veteran of U.S. Armed Forces..
07/13/2014 8 7 yrs . War or Dates N/A
--- - ------ -
H Place of Death Hospital, Institution or
W_ City, TaXAMIacirgX Gloversville Street Address Nathan Li.tti uer Hospital
�p Manner of Death Natural Cause n Accident C Homicide Suicide ❑Undetermined Pending
ll Circumstances Investigation
W Medical Certifier Name Title
CI Margaret E. Luck Coroner
Address ----__-- _ _ .
223 West Main Street , Johnstown , NEw York 12095
Death Certificate Filed District Number 1 Register Number
City, lavUnititAX Gloversville 1701 I 148
❑Burial ( Date Cemetery or Crematory
07/15/2014 Pine View Crematory
❑Entombmentt A
Address
@cremation Queensbury , New York
Date Place Removed
Z Removal and/or Held
° C and/or
Address L
Hold
0
O Date Point of
Transportation Shipment
1
a by Common i Destination
Carrier
�j 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 , New York 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped. if Other than Above
g Address
CC
W---- — _
CL Permission is hereby granted to dispose of the human remains described above'as indicated.
Date Issued 0 7/15/2 014 Registrar of Vital Statistics 6Liket t(
(signature)
District Number 1701 Place City of Gloversville
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition,1'ig_1t Place of Disposition owv p i
2 (address)
W
Cr Name of Sexton or Person in Charge f Premises (section) ffr�lOIt number)�SOnnb� (grave number)
g
Z (p)ease print)
W Signature — - Title C1? 4h
(over)
DOH-1555 (02/2004)