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Monroe, Elizabeth ` # 31 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Elizabeth B. Monroe Female Date of Death Age If Veteran of U.S. Armed Forces, June 13,2013 90 War or Dates Place of Death Hospital, Institution irondack Tri-County Health Care Z City, Town or Village Johnsburg Street Address Center Wp Manner of Death I X Natural Cause I ]Accident 1 I Homicide Suicide Undetermined Pending W Circumstances Investigation tu Medical Certifier Name Title CI Nancy Carney Dr. Address HHHN,Wrg.,NY 12885 Death Certificate Filed District Number Register Number /y City, Town or Village Johnsburg 5655 ❑Burial Date Cemetery or Crematory Entombment June 14,2013 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury,NY 12804 Date Place Removed Z I- I Removal and/or Held 52 and/or Address H Hold u) 0 Date Point of Ni !Transportation Shipment p by Common Destination Carrier I 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 1— Remains are Shipped, If Other than Above 2 Address WIL Permission is hereby granted to dispose of the human rem ins descr' ed eve as indicated. Date Issued 6 /3 Registrar of Vital Statistics l/t�U�(eit, 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 uuDate of Disposition b-f1-13 _ Place of Disposition gelat,,,�., W (ad ress) N fY (section) Ali(lotnumber) (grave number) p Name of Sexton or Person in Charge f Premises s St - Z (Tease print) W r Signature Title CQcr�a coQ. (over) DOH-1555 (02/2004)