Mitchell, Allison NEW YORK STATE DEPARTMENT OF HFALTH,1 j
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Allison Jean Mitchell Female
Date of Death Age If Veteran of U.S. Armed Forces,
ns/n2/2n13 36 years War or Dates
}- Place of Death Hospital, Institution or
City, Tow d Street Address
f ij XX Glens Falls Glens Falls Hospital
Manner of Death❑Natural Cause Accident Homicide Suicide Undetermined Pending
t Circumstances Investigation
La Medical Certifier Name Title
O Ageel A. Gillanl M l
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
< City, Towrit \(fill x C-Ileps Falls 5601 91
0 Burial Date Cemetery or Crematory
[]Entombment Address
Pine View Cemetery
Address
>jj ❑Crpmation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
w= Hold
4
0 Date Point of
011[�Transportation Shipment
Q by Common Destination
Carrier
Q Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address O:ii
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
1
tU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2013 Registrar of Vital Statistics W C/,i -NQ.,- LA)
(signature)
District Number Place
5601 glans Falls
LI I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ta Date of Disposition Z-5't3 Place of Disposition -{,,.,,,4ti , CK+n,ftt..-
1 k (address)
ill
IX (section) I (lot number) - (grave number)
aName of Sexton or Person in Charge Premises il,t �O P/fj-
2 74(.11—
(please print)
Signature Title CitiA
(over)
DOH-1555 (02/2004)