Weller, Josephine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
» Name First Middle Last Sex
Josephine S. Weller Female
Date of Death Age If Veteran of U.S. Armed Forces,
58 War or Dates None
Place of Death Hospital, Institution or
City, T NUX1{t1idW Glens Falls Street Address Glens Falls Hospital
Manner of Death®Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
12885
Death Certificate Filed District Number Register Number
City, ,XdJk UX,D(nWX Glens Falls 5601 /02
Date Cemetery or Crematory
Burial March 17, 1999 Pine View Crematory
Address
Cremation Quaker Rd. , Queensbury, N.Y. 12804
� Date Place Removed
Z ❑Removal and/or Held
and/or Address
Hold
C Date Point of
[--]Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00022
Address
3809 Main St. , Warrensburg, N.Y. 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described pbov as i i a d.
Date Issued 3/15/99 Registrar of Vital Statistics `
(signature)
District Number 5601 Place Glens Falls City Clerk's Office, Glens Falls, N,Y, 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Dispositio — Place of Disposition
(address)
LU
N
M �tion) (lot umber (grave number)
Name of Sext or Person in Charge of Premises ,� /YI T
g (please print) /.y
L� Signature •fij,2, occ� Title _ /��� / c-
DOH-1555 (10/89) p. 1 of 2 VS-61