Isachsen, Anastasia NEW YORK STATE DEPARTMENT OF HEALTH f
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anastasia M Isachsen Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/26/2013 93 years War or Dates
:- Place of Death Hospital, Institution or
W City, Towj(ilX Glens Falls Street Address the Pines Nursing Home
D Manner of Death Nptural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
at Medical Certifier Name Title
Bernardo RVillajuan M f)
Address
161 Carey Road Queensbury, Ny 12804
Death Certificate Filed District Number Register Number
City, Tows 3Cj(ill0ggfXX . Glens Falls 5601 229
:❑Burial • Date • Cemetery or Crematory
❑Entombment 05/28/2013 Pine View Crematorium
Address
l,Cpemation Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
9, and/or
Address
Ill
0 Date . Point of
d Transportation Shipment" _
t
0 by Common Destination
Carrier .
Disinterment Date Cemetery Address
: '<'.Q Reinterment Date. Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mc Dermott Funeral Home, Inc. 00141
Address .
9 Pine Street Chestertown, N Y 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
W.A.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/28/2013 Registrar of Vital Statistics l,A) C A U\Y-A^-ket-
(signature)
District Number 5601 Place Glens Falls
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z //11
l Date of Disposition 513a113 Place of Disposition 2.41)04.-d (s (ot;v' ,
(address)
ill
U)
11 (section) (lot``�umber) (grave number)
Name of Sexton or Pers n in Charge of Premises kyle_ 3 fortff
Z (pl ase print)
Signature Title tkCt (L
(over)
DOH-1555 (02/2004)