Goodnow, Viola May ti- 7 sti
Lr_-- s
NEW YORK STATE DEPARTMENT OF HEALTH -
Bureau of Vital Records BurialTransit Permit
t
Name First Middle Last Sex
Viola May Goodnow Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/03/2022 77 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Ticonderoga Town Street Address Elderwood at Ticonderoga
ILI
p Manner of Death El Natural Cause Accident El Homicide ESuicide Undetermined Pending
W U Circumstances Investigation
0 Medical Certifier Name Title
Kristin Mack DO
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed Town Of Ticonderoga District Number Register Number
City,Town or Village 1564 60
Burial Date Cemetery,Crematory or Facility Name
12/06/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
EiDonation
OZ EIRemoval Date Place Removed
H and/or and/or Held
N Hold Address
0
IQ. Date Point of
U) Transportation
p by Common Shipment
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
1— Remains are Shipped,If Other than Above
S Address
CC
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2022 Registrar of Vital Statistics Tonya M'Thompson(E(ectronica((ySigned)
(signature)
District Number 1564 Place Town Of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate ..
of Disposition oil ZZ Place of Disposition i F kL L
2 /address)
W
Cl) (section) /lot number/ (grave number)
S Name of Sexton or Person in Cha a of Premises 4,,,t,
C �Z
Ili Signature Title ft /m (Z.1f
DOH-1555(07/18)p 1 of 2
._o 4
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#