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Converse, Roberta Ann NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Roberta Ann Converse Female Date of Death Age If Veteran of U.S.Armed Forces, 08/29/2021 88 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 1 April Lane,Queensbury Town, New York 12804 Manner of Death Pending ©Natural Cause Accident Homicide Suicide Undetermined Circumstances Investigation W Medical Certifier Name Title Andrew Garner MD Address 8 Harrison Harrison Avenue,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 179 ❑Burial Date Cemetery,Crematory or Facility Name 09/01/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury Town,New York 0 Donation Z Removal Date Place Removed and/or and/or Held Hold Address N 0 O. Date Point of U) Li Transportation Shipment by Common Carrier Destination 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 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/31/2021 Registrar of Vital Statistics Caroline WiCdegarc[e Barber(ECectronica(CySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ~ ql( I� Z Date of Disposition Place of Disposition 47 2 (address) W re N (section) got number) (grave number) 8 Name of Sexton or Person in Charge of Pre ises 417 nk Z ( ase print) W Signature Title ��I' DOH-1555(07/18)p i of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#