Cleveland, Patricia NEW YORK STATE DEPARTMENT OF HEALTH „ ii
5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia L. Cleveland Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 17,2014 54 War or Dates
8, Place of Death Hospital, Institution or
City, Town or Village T/O Johnsburg Street Address Route 28
a Manner of Death I XI Natural Cause Accident I 1 Homicide Suicide Undetermined Pending
uf, Circumstances Investigation
w Medical Certifier Name Title
Darci Ann Gaiotti-Grubbs
Address
102 Park St.
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 02 l
❑Burial Date Cemetery or Crematory
Entombment August 19,2014 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
O.
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
2, Address
tL Permission is hereby granted to dispose of the human re ains described above as 'ndicated.
Date Issued SaP1.9"4)14 Registrar of Vital Statistics , b 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 '/791l4 Place of Disposition 'Pi— C,, i,,s
2 (address)
W
CO
p0 (section) ',Lill.,_ (lot n ber) (grave number)
Name of Sexton or Person i Charge of Premises Jt►. -
Z (please print)
W
Signature )lie _
Title L'kw►?Cdit
(over)
DOH-1555 (02/2004)