Baldwin, Anita 4
NEW YORK STATE DEPARTMENT OF HEALTH, t 35(..
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anita Pearl Baldwin Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 5, 2013 75 War or Dates
Z Place of Death Hospital, Institution or
toCity, Town or Village Fort Ann Street Address 577 Buttermilk Falls Road
WManner of Death Natural Cause El Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
0 Circumstances Investigation
W Medical Certifier Name Title
0 Craig A Emblidge MD,
Address
3 I ngate Center Glens Falls, NY 12801
Death ificate Filed District Nu �s Register Nun/ r
City, or Village �
❑Burial Date Cemetery or Crematory
June 6, 2013 Pine View Crematorium
`,❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
.. Hold Pine View Crematorium
CA Date Point of
d ❑Transportation Shipment
CO by Common Destination
(3,, Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
11_ Remains are Shipped, If Other than Above
2 Address
W''
0' Permission is hereby granted to dispose of the human re ' s described above as i cate .
Date Issued G— 9 c2O/3 Registrar of Vital Statistics �, , - Jr LO
(signature)
District Number 2s Place c9M t & , _— y
/Z Z
i-- I certify that the remains of the decedent identified above were disposed ofof in accordance with this permit on:
W; Date of Disposition ip II 1)3 Place of Disposition '[►4e) 6 P'ch'`"
(address)
W,
CO (section) (lot l umber) ('' (grave number)
0 Name of Sexton or Person i Charge of remises fL I t J��N�
Z' (p ase print)
al'° Signature L Title CtiemffilT
(over)
DOH-1555 (02/2004)