McKeon, Alice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice Joan Mckeon Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/15/2013 74 years War or Dates
Pie of Death Hospital, Institution or
/City 1TowxgyillgXX Glens Falls Street Address park st glens falls,n y 12801
0 ner of Death I tural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
>d Timothy E. Murphy Coroner
Address
52 Haviland Ave Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
ity, TowiXpfx ill lXX Glens Falls 5601 392
Burial Date Cemetery or Crematory
❑Entombment 09/17/2013 Pine View Cemetery
Address
C4emation Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
F_ Hold
U.)
C? Date Point of
0❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
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
2 Address
W
fl Permission is hereby granted to dispose of the human remains describe above as .ndi
Date Issued 09/17/2013 Registrar of Vital Statistics �4 . .y
(signature)
District Number 56ni Place Glens Falls /PI/ /)SY/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition 0%113 Place of Disposition -t,,, �� rd- for 0--
2 (address)
Lu
CO
CC (section) (lot umber (grave number)
0
• Name of Sexton or Person in Charge of remises (.4 S"
(pllease int)
Signature Title C12k'M(filde
(over)
DOH-1555 (02/2004)