Busser, Alicia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alicia Stewart Busser ' Female
Date of Death 1 Age If Veteran of U.S. Armed Forces.
April 28, 2013 ! 96 • War or Dates No
I- Place r Guth Hospital. Institution or
Z Tov✓n
LU xxt Warrensburg.,, Street_ Address 5 Palermo RD., Chestertown, N.Y._
Manner of Deat
� Natural Cause n Accident n Homicide �Suicide C Undetermined I I Pending
W Circumstances Investigation
C)
W Med:cal Certifier Name Title
CI
Paul Bachman___ M.D.
Address
3767 Main St., Warrensburg, N.Y. 12885
Death Certificate Filed District Number — ^, ^ Register Number
tbtlic Town o i¢ { Warrensburg `J hL LX D 10
ElBur,al Date Cemetery or Crematory
May 1 , 201.3. _ - -- Pine View Crematory _
Address
CCremation Quaker Rd., Queensbury, N.Y. 12804
Date Place Removed
Z I Femo o and/or Held
0 or Address
CO
0 _ Date Point of
NTransportation Shipment
a by Com;non Destination
Carrie!
Disinter ment Date Cemetery Address
R interment Date Cemetery Address
Permit Issued to - . -j I Registration Number
Name of Funeral Home i \r ,vI i 1(_�1 (i 1 ) V-_)c , k,i i t ,I It • i, ( } ( ',1 ) I C
Address (- V
' f t l ( , . t( , \ 7 ) it III )( J ��( i
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Adc -ess
i'Z
W —
a' Permission is hereby granted to dispose of the human remai s scribed abo e as indicated:
Data Issued 4/30/2013 Registrar of Vital Statistics ��
(signature)
District Nirmber�to(0Q Place Warrensburg Town Clerk's Office, Warrensburg, N.Y. 12885
I cer t�ty that the remains of the decedent identified above were disposed of in accordance withit� this permit on:
WDatcof Disposition S-t,-0 Place of Disposition iut1,,J C r4^1.4f!vit.-
W (address)
U)
CC (section) (lot number) (grave number)
p Nam: of Sexton or Person in Charg of Premises A�s�_ lN
Z (pie se print)
W Signature Title C C_
(over)
DOH-1 (02 2004)