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Bormann, Patricia NEW YORK STATE DEPARTMENT OF HEALTH • 'r 7 Vital Records Section Burial - Transit Permit s;` E Name First Middle Last Sex Patricia R. Bormann Female Date of Death Age If Veteran of U.S. Armed Forces, °="=_ January 1,2012 80 War or Dates Place of Death Hospital, Institution or :Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital lit Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Imo' Circumstances Investigation Medical Certifier Name Title ::0; Nancy Carney Dr. Address HHHN,Warrensburg,NY 12885 Death Certificate Filed District Number Register Number City, Town or Village Glens Falls 5601 Z— ❑Burial Date Cemetery or Crematory El Entombment January 3,2012 Pine View Crematory Address ❑x Cremation Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address N Hold N 0 Date Point of coTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number ={s 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 Remains are Shipped, If Other than Above Address 5s . Permission is hereby granted to dispose of the human remains desc/ '';bb dd bo as ' ated. Date Issued ©// /2/4'Registrar of Vital Statistics /2" �" (signature) District Number 5601 Place Glens Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z i� /' W Date of Disposition I-iI-IZ Place of Disposition n4U,i1� C�wri.4orauv. 2 (address) W Cl) Et (section) 4r, (lot number) (grave number) pName of Sexton or Pe on in Char a of Premises �N �r' Jf„,�(i- Z (please print) W L Signature C ( Title Cile m PM& (over) DOH-1555 (02/2004)