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Coon, Alice R It tt7 • NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Alice R.Coon Female Date of Death Age If Veteran of U.S.Armed Forces, 08/04/2021 94 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W Manner of Death CI ©Natural Cause El Accident 0 Homicide El Suicide �Undetermined �Pending CU' Circumstances Investigation WW Medical Certifier Name Title Carrie Miron PA Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 44 EIBurial Date Cemetery,Crematory or Facility Name 08/06/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation Removal Date Place Removed and/or and/or Held ~ Hold Address rn 0 d Date Point of U) Transportation p by Common Shipment Carrier Destination LI 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 Remains are Shipped,If Other than Above Address CC W rZ Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/05/2021 Registrar of Vital Statistics Aimee G Makoney(ECectronicalTy Signed) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition g�R Z1 Place of Disposition �Ld� 2 (address) W N (section) A (lot number) (grave number) Name of Sexton or Person in Ch rge of Premis f/ +hi Z (p se print) LU Signature Title L 1 t DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) 01501 Receipt J Human remains of 1 del vered on _., , 20 ,r i Pine View Cemetery Reprrese r ng the funeral home named on burial permit Official Funeral Directors Reg.or License# •''" z '7