Monroe, Anne . . . tt (it
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne M. Monroe Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 14,2013 64 War or Dates
.. Place of Death Hospital, Institutiontifirondack Tri-County Health Care
Z City, Town or Village Johnsburg Street Address Center
im
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name Title
G Thomas Warrington
Address
HHHN,Johnsburg,NY 12843
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 3 1
❑Burial Date Cemetery or Crematory
❑Entombment October 17,2013 Pine View Crematory
Address
Ex Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
ZO I 'Removal and/or Held
and/or Address
i' Hold
U)
0 Date Point of
N 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 00035
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
W
a
Permission is hereby granted to dispose of the human re ' s described bove as ndicated.
Date Issued OC'.:?/- 14,a - Registrar of Vital Statistics L___.d n Ci.), o
(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:
uiDate of Disposition i/0 f Ig 113 Place of Disposition ' ? t,4ev C iw,,RJfor,,,,�.
M (address)
Cl)ILI
CL (section) /L. (lot number) �^^ (grave number)
Z Name of Sexton or Pers n in Charg of Premises 31041-
(phase print)
W
Signature ft_ Title CiQEN1/}iW
(over)
DOH-1555 (02/2004)