Cole, Geneva S NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
...... .en..e. :a.::.....5..,....:....C.o.l..e.. .::::.: :....... _:: ...:.:.. .. F.F.m.a::l e.
Date of Death Age If Veteran of U.S.Armed Forces,
May 5 , 1991 65 War or Dates N 0
........ ::..:.....:.. : ..........................................................::.:...... ..... .............
Place of Death Hospital, Institution or
Z
City, I Street AddressG l e.►1 s Falls Hospital
, ..
�iP�'R�'X � ....:....G-..e:.n.s. .F.a.l a s .......... .:..:: .............. _ .........:...:............ ............ ......
W Manner of Death ® Natural Cause Accident Homicide ❑ Suicide Undetermined Pending
Circumstances Investigation
............ ......:.. . ........... ... .... ..... .:::... ....................... ..... ... ............... ......... .................. . ... .....
Medical Certifier Name Title
o Howard P . Fritz M. D .
..... ...................:::.::.....:..................................:.......:..... ...... ............ .......................... ................ ............
Address
100 Park St . , Glens Falls , N . Y . 12801
_ ........... ....... ............................:................... . ..... _........ ...... .... ... . .........
Death Certificate Filed District Number Register Number
City,R"Ky(I Nq( Glens Falls 5601
aJ��
Date Cemetery or Crematory
❑Burial May 9 , 1991 Pine View Crematory......
Y ............................ _,.... ......... ::......: .....:.
[Cremation Address
Queensbu:rY , :N . Y .:.: __.
Z Date Place Removed
0I', ❑ Removal and/or Held
F—' and/or Hold ..... ........ ........ ........:...... :: .. ..:. . . _ ....:.:..... ..
Address
N','
O:.:.::... .....
L Date Point of
an'; Transportation by Shipment
p' Common Carrier -.........:.:....:..... .... : ......
Destination
.. ........ . . .......
..............
Disinterment Date Cemetery Address
......... _ .....:.......... . ,: ..:.: ....... .. .::...... _.... ..::...
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Alexander Baker Funeral _Home;. . 0:001,4,...
.... ... ............................ . ... ............... . ......... ...
Address
....... ..... �.:�.4...:Ma 1.n..:St:...:,::...Warrens.bu.r.9�: N:::Y::.... 1.2,885::::::..
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
...::::.. ...:.. ,.
....:.::::...........
Address
ol:.
a
... ....... ................................ ...... .. . ....... .
Permission is hereby granted to dispose of the humAn remains described above as indicated.
Date Issued M a y 7 , 19 9 1 Registrar of Vital Statistics ?
(signature)
District Number tint Place City Hall , Glens Falls , N .Y .
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition;-��� Place of Disposition P%�'�/e V 1 e-� <` %�K e ��(�I �/ t
W (address)
N^ (section) (lot number) (grave number)
cc
0'< ,/►,�
Q Name of Sexton or Person in Charge of Premises /// ,C Z-
Z (please print)
w Signature Title �g t1j I4SS/7-
DOH-1555 (10/89) p. 1 of 2 VS-61