Robbins, Dawn it '(02
NEW YORK STATE DEPARTMENT OF HEALTH-I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dawn P. Robbins Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 29,2012 55 War or Dates NA
.. Place of Death Hospital, Institution or
Z City, Town or Village Hudson Falls Street Address 54 King St.
p Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
w Medical Certifier Name Title
C3 Edward S.Parsons Coroner
Address
17 Prospect St.,Granville,NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village Hudson Falls 5726 I j
❑Burial Date Cemetery or Crematory
August 2,2012 Pine View Crematory
El Entombment Address
❑x Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
t: Hold
N
O Date Point of
Nl I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
IReinterment Date Cemetery Address
IPermit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
CZ
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7-31-12 Registrar of Vital Statistics
(signature)
District Number 5726 Place Village of Hudson Falls,NY l of 3`j
H
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (-I'I'L Place of Disposition gmUtva 64-tord.•
rL (address)
w
CO
O (section) - (lot number) c (grave number)
QName of Sexton or Person in Charge of Premises �i r,,T t" J,..-41-
Z (please print)
w Signature _______Ay_____, Title ChA-kl q-'A-
(over)
DOH-1555(02/2004)