Persons, George t t 1 3
NEW YORK STATE DEPARTMENT OF HEALTH ' t
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George L. Persons Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 20,2012 72 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Johnsburg Street Address 54 Sodom Cross Road
a' Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
in Circumstances Investigation
W Medical Certifier Name Title
a Daniel Way
Address
MIEN,North Creek,NY 12853
Death Certificate Filed District Number Register umber
City, Town or Village Johnsburg 5655 i6
❑Burial Date Cemetery or Crematory
April 23,2012 Pine View Crematory
0 Entombment Address
®Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E' Hold
N
0 Date Point of
N I I Transportation 1 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 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1—' Remains are Shipped, If Other than Above
2 Address
CC
tti
Q. Permission is hereby granted to dispose of the human ains describedabove as in icated.
Date Issued Registrar of Vital Statistics �. �, , ....,._
.7
ignature)
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 'I
Date of Disposition 4 I1 I..`1 h i. Place of Disposition ,r VlN r�tmdfer,...
(address)
W
co
re (section) n� (lot number)/ (grave number)
pName of Sexton or Person in Charge of Premises L rn}fpl., J1.d
Z / 1 (please print)
ILI
Signature Ala---
Title Cieiv111-TU�
(over)
DOH-1555 (02/2004)