Vanselow, Dawn # - r)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ' Burial - TransitPermit
Name First Middle Last Sex
Dawn R. Vanselow Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 25,2013 83 War or Dates
Place of Death Hospital, Institutiorl1irondack Tri-County Health Care
City, Town or Village Johnsburg Street Address Center
d Manner of Death X Natural Cause I 'Accident [ (Homicide Suicide Undetermined Pending
rut
Circumstances Investigation
ruf Medical Certifier Name Title
0 Thomas Warrington
Address
r " HIEINN,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 d`7
❑Burial Date Cemetery or Crematory
Entombment May 28,2013 Pine View Crematory
Address
Ex Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
I' Hold
c
O Date Point of
l "Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
H 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
le
Permission is hereby� granted to dispose of the human remai described ab as indicated.
Date Issued _u1 1 aU/,3Registrarof Vital Statistics L�[J�C�Clt.e)-�
(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:
Z � {W Date of Disposition S/Z��3 Place of Disposition „J.��;,,, vt4
2 (address)
W
CO
Ce
(section) tit
lotnu ber) (grave number)
p Name of Sexton or Perso in Charge of remises pHNft
Z (ple a print)
W Signature Title (17Mt?Cd�t
d
(over)
DOH-1555 (02/2004)