Cleveland, Annie *tilt
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Annie I. Cleveland Female
Date of Death Age If Veteran of U.S.Armed Forces,
March 22,2012 59 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 678 Hudson St.
p Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
W• Medical Certifier Name Title
O Dr.James Hicks,MD
Address
HHIIN,North Creek,NY 12853
Death Certificate Filed ' District Number Register Number ry
City,Town or Village Johnsburg 5655 j�
❑Burial Date Cemetery or Crematory
Entombment March 26,2012 Pine View Crematory
Address
Ix Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
ORemoval and/or Held
and/or Address
H Hold
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped, If Other than Above
• Address
CZ
a
Permission is hereby granted to dispose of the human remains .es ribeab411,7 s indicated.
Date Issued (J3I3j oZ i i2 Registrar of Vital Statistics �✓
/ (signature)
District Number 5655 Place Johnsburg
1—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3-11-it. Place of Disposition Pica Ut ew fa
(address)
W
(section) A (lot numbe (grave number)
O
p Name of Sexton or Person in Charge QQgf Premises I br4tRy1-4,-
(please print)
LU
Signature Title OleWAtiO/l.
(over)
DOH-1555 (02/2004)