Baker, Helene NEW YORK STATE DEPARTMENT OF HEALTH ', Burial Records Section Burial - Transit Permit
... Name First MiddleLast Sex
Helene Patricia Baker Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 27,2017 77 War or Dates
Place of Death Hospital, Institution or
.i City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident n Homicide n Suicide Undetermined I I Pending
Circumstances Investigation
Medical Certifier Name Title
Stephen Peruzzelli,MD
Address
Glens Falls,NY
Death Certificate Filed District Number RegisterNirnber.\s. City, Town or Village �t-1,Li
❑Burial Date Cemetery or Crematory
May 1, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
0 and/or Address
E • Hold
CO
0 Date Point of
u) ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Ws
. Address
in 94 Sarato.a Avenue, South Glens Falls2_NY 12803
Name of Funeral Firm Making Disposition or to Whom
. , Remains are Shipped, If Other than Above
; Address
Permission is hereby granted to dispose of the human remains described above as indicated.
my
Date Issued 5 t i ` 17 Registrar of Vital Statistics WCAA.AryN12,
ATi
(signature
District Number r_, (70( Place 6S RC). \`S i N
t I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition S I a l (1 Place of Disposition 'Pint ta i tv.-t"—
W (address)
La
Ct (section) 1 Alot number) (grave number)
p Name of Sexton or Person in Charge of Pre ises /`rs" le,rt 1/t
Z (please print)
W Z2 Title f i��i
Signature
(over)
DOH-1555(02/2004)