Martindale, Ann NEW YORK STATE DEPARTMENT OF HEALTH # qt16
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ann M. Martindale Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 17,2013 78 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street-Address 10 Manor Road
cl Manner of Death X Natural Cause Accident _iiiHomicide I `Suicide I 'Undetermined Pending
Ui Circumstances Investigation
w Medical Certifier Name - Title
CZ Daniel Sooriabalan
Address
HHHN
Death Certificate Filed District Number Register Number
City, Town or Village Johnsburg 5655 (94
❑Burial Date Cemetery or Crematory
ombrr�nt August 19, 2013 Pine View Crematory
Address
lx Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
O and/or Address
F' Hold
co
0 Date Point of
yI I 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 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
ce
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Permission is hereby granted to dispose of the human remai s describe_d abas indicated.
Date Issued ` /3 Registrar of Vital Statistics itU._ ._' C-
(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 Cow.t
W Date of Disposition q i Zds 5Place of Disposition ,��e,J (t t':.,.,
W (address)
U)
CC
(section) Apot num er) (grave number)
p Name of Sexton or Person i Charge of P mises ,s gngtt
Z (pleas print)
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Signature Title C12+E PtA 1 .
(over)
DOH-1555 (02/2004)