Augusta, Halah * 310
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middy Last Sex
Halah L. Augusta Female
Date of Death Age If Veteran of U.S.Armed Forces,
June 14,2012 72 War or Dates
.. Place of Death Hospital, Institution or
`Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death g Natural Cause Accident I I Homicide Suicide Undetermined Pending
u•i Circumstances Investigation
U
uw Medical Certifier Name Title
0 Nancy Carney Dr.
Address
HHHN,Wrg.,NY 12885
Death Certificate Filed District Number Register NI ber
City, Town or Village Glens Falls 5601 oe
❑Burial Date Cemetery or Crematory
Entorribrrient June 15,2012 Pine View Crematory
III Address
❑X Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address •
H Hold
fn
O Date Point of
NTransportation 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 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
r
to
O. Permission is hereb granted to dispose of the human remains descriebov s i a d.
Date Issued 0 /11-0/2- Registrar of Vital Statistics
i nature(s g )
District Number 5601 Place Glens Falls f//T /02 ji/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uzi Date of Disposition 6111,I IT, Place of Disposition .gwUuv Crkitor1i.I-
u (address)
uJ
V)
W (section) lot number) (grave number)
pName of Sexton or Person in Charge of Premises a tor S.1.4i.
Z g /J4 (pleaseprint)
w Si nature (/ �jj Title NGM ��1.
r (over)
DOH-1555 (02/2004)