Van Schuyler, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Date of Death Age If Veteran of U.S. Armed Forces,
12 99 War or Dates No
Place of Death Hospital, Institution or
Town � Johnsbur Street Address Adirondack Tri Count Health Care F cilitj
Manner of DeathEgNatural Cause Accident Homicide Suicide 0 Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Address
North Cral Nort
Death Certificate Filed District Number Register Number
Town 40 i� J
Date Cemetery or Crematory
❑Burial Oct. 14 1999 Pine View Crematory
Address
FA Cremation ueensbur N.Y. 12804
Date Place Removed
z❑Removal and/or Held
and/or Address
Hold
Q Date Point of
Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00017
Address
Rt. 28, North River, N.Y. 12856
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 above as indicated.
Date Issued 10/14/96 Registrar of Vital Statistics �r ►�L tom__ ���r �z x f
(signature)
District Number 56_95 Place Johnsburct Town Clerk's Office, North Creek, N.Y. 12853
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 6 Place of Disposition f ir15(�!/,: s C��/✓�19 O /640
W (address)
mi
0
>� (section) (lot number) (grave number)
GName of Sexto or Person in Charge of Premises .t�,��✓��►� /����
a (please print) ,
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61