Walker, Agatha A \
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NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Agatha A Walker Female
Date of Death Age If Veteran of US.Armed Forces,
10/28/2022 83 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined ❑Pending
W0 Circumstances Investigation
Medical Certifier Name Title
C1 Kasandra Frasier PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 545
Burial Date Cemetery,Crematory or Facility Name
® 10/31/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
Date Point of
(/) Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/31/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Date of Disposition /I `-ZG 7Z Place of Disposition Ak? L/;ei,i) r('.pi1 4'
g (address)
w
N CC (section) (i num r) (grave number)
0 Name of Sexton or Person in Charge Pre .ses r7 mmib l ��
Z (please print)
W Signature Title t -0 4749 r
DOH-1555(o7/t8)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 •
Pine View Cemetery Representing the funeral home named on burialAermit
Official Funeral Directors Reg. or License#