Mason, Joanne # �sli
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Joanne M. Mason Female
Date of Death Age I If Veteran of U.S. Armed Forces,
December 9,2012 67 War or Dates
F Place of Death Hospital, Institution or
�Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death X Natural Cause I I Accident I I Homicide Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
G Dr.John Rugge
Address
HI-IHIN,Warrensburg,NY 12885
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 j ��
❑Burial Date Cemetery or Crematory
❑Entombment December 11,2012 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
I— Hold
U)
0 Date Point of
yTransportation 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
I-. Remains are Shipped, If Other than Above
2 Address
Ir
u!
0-
Permission is he eby granted to dispose of the human €nains d cribed abo • as indica•-
d.
Date Issued % Q Uf Registrar of Vital Statistics Dj_ , Pam. � •'_' L
(stgnafurd)
District Number 5601 Place Glens Falls
I-
I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
uwi Date of Disposition IL-13'I , Place of Disposition „1.Xtu C r,0-
2 (address)
W
0 (section)
(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises fi11 A,i_ —calf
Z (p/e se print)
WIcL-- ./1.14— Title OMoo lq-1-04_
Signature
(over)
DOH-1555 (02/2004)