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Cleveland, Ada R Sb NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle .., Last Sex Ada R.Cleveland Female Date of Death Age If Veteran of U.S.Armed Forces, 11/25/2023 87 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek p Manner of Death El Natural Cause EAccident Homicide Suicide Undetermined riPending (Wj Circumstances Investigation QW Medical Certifier Name Title Leah Terry NP Address 4573 State Route 40,Argyle Town,New York 12809 Death Certificate Filed Town Of Johnsburg District Number Register Number City,Town or Village 5655 52 Bdrial Date Cemetery,Crematory or Facility Name 11/30/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed F- and/or and/or Held N Hold Address 0 O. Date Point of CO 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 F.. Remains are Shipped,If Other than Above S Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/30/2023 Registrar of Vital Statistics Jean Comstock(ECectronica(CySigned) (signature) District Number 5655 Place Town Of Johnsburg I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition /Z ,(�-Z.-ZCl3 Place of Disposition 0 r ie vt`C' ,.� Cr ein 41 r-1 2 (address I ii CC N (section) (lot num r) (grave number) 8 Name of Sexton or Person in Charg Pre es —7740r20.1b Z r (please print) W Signature Title �'�-� DOH-1555(07/18)p 1 of 2 6�6���"1" 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#