Gaffney, Alma F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Alma
........................................................................................ ... ............. ...........................Gaffney. ......................... ......Female
.............................. ..........
Date of Death Age If Veteran of U.S.Armed Forces,
1-1-91 88 War or Dates NA
............................ ............ .......
. ...................... ............................. ................................ .............................................. ........ ........................... ...........................................
Place of Death Hospital, Institution or
Street Address City,Town or Village john burg
S Adirondack Tri-Coun _N.....H
.................. ........ .......... ................................ ...........
......................................................... ..................................................... ............. ty........................................
Manner of Death F Ei Undetermined 0 Pending x� Natural Cause Accident F� Homicide E] Suicide
...... Circumstances Investigation
0.� ..........................__......................................... ........................................... ..............
.. ........... . . ....................................... .............................. .................... ............... ...
Medical Certifier Name Title
:0 Bryan Smead M.D.
..................................................................................................................... .......................................................................................................................... ...............
Address
Warrensburg,N.Y.
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Death Certificate Filed District Number Register Number
City,Town or Village Johnsburg 5655
Date Cemetery or Crematory
E]Burial 1-4-91 Pine View Crematory
.. ............. ......... ........................................................................................................ .......................................... ................. ...........................................
09Cremation Address
.......................................................................................................-............ .......................I....................................................................................
z Date Place Removed
0 E] Removal and/or Held
I- and/or Hold Address............................. .............................'.:............................................................................... ........................................... ...............
Fri
0................................ ................................................................... .................................... ..... .....
CL Date Point of
cn E]Transportation by::
Shipment
CommonCarrier ... .................. ...................................................... .................. .................
Destination
.............................. ........................... .........................❑ ................................ ...............................................................................................................
Date Cemetery Address
Disinterment
❑
............................I-............... ............. ........... .......................................... .................
Date Cemetery Address
Reinterment a
....... Permit Issued to Registration Number
Name of Funeral Firm Alexander-Baker F.H....... 00014
...........
...................... .............................................................. ...... ......... ............................. ........................... ....... ....................... .......
Address
114 Main St,Warrensburg,NY 12885
..........................................,......11.............................................................................-........................................ ...........................
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
................11 ...... ................... ....................................................................... ..............................
.....................................................................................................................................
Address
ILI.
............. ........................................................... ..........-....... ................
.................................................................................................... .........
Permission is hereby granted to dispose of the hums i,remains describe above as indicatecl.
7
Date Issued 1-4-91 Registrar of Vital Statistics
(signature)
District Number 5655 Place Town of Johnsburg,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z Date of Disposition /- 7-& Place of Disposition (f h772
W
2 (address)
�LLI.
cl): (section) (lot number) (grave number)
0C
0
C) Name of Sexton or Person i Charge of Premises
e
.z (please print)
P�'Signature Title C/? M Z_
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DOH-1 555 (10/89) p. 1 of 2 VS-61