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Waterston, Thelma Lois
1130 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex it Thelma Lois Waterston Female Date of Death Age If Veteran of U.S.Armed Forces, \ 05/17/2021 85 Years War or Dates 1954-1955 t .. Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek pManner of Death ©Natural Cause ElAccident ❑Homicide ID Suicide ElUndetermined ❑Pending Circumstances Investigation E Medical Certifier Name Title James Hindson MD Address 112 Ski Bowl Rd,Johnsburg Town,New York 12853 Death Certificate Filed District Number Register Number p City,Town or Village North Creek 5655 17 ❑Burial Date Cemetery,Crematory or Facility Name 05/19/2021 Pine View Crematory ❑Entombment Address �, X❑Cremation Queensbury Town,New York ' �Donation O El Date Place Removed and/or and/or Held LI N Hold Address 0 Cl) ❑Transportation Date Point of CI -by Common Shipment 4 Cilrrier Destination .30 Disinterment Date Cemetery Address ❑Reinterment Date - Cemetery Address ,' Permit Issued to Registration Number = Name of Funeral Home Alexander Baker Funeral Home 00037 Address • 3809 Main St,Warrensburg,New York 12885 Name of Funeral Firm Making Disposition or to Whom F=_ Remains are Shipped,If Other than Above 2 Address 5 a'. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/18/2021 Registrar of Vital Statistics 2(pth(een C.Lorah(ECectronicatTySigned) (signature) District Number 5655 Place North Creek, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z �f t ru Y.� 7 a� Date of Disposition ,��(`� /Zf Place of Disposition �� 11.1 2 (address) W f l) (section) A(lot number) (grave number) gL A� t1�. 't' Name of Sexton or Person in Charge of Premises ,�' Z (plea print) W SignatureZ Title CPC w DOH-1555(07/t8)p t of 2 Public Health Law Sec. 4145(2b) 3 14 7q8 Receipt Human remains of delivered on , 20 i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#