Nerf, Joan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan Emily Nerf Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/20/2017 86 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident 0 Homicide Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
f;.
Suzanne Rayeski DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 341
®Burial
Date Cemetery or Crematory
06/23/2017 St.Alphonsus Cemeter
£_❑Entombment
t — Address
❑Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or
Address
Hold
Date Point of
r4 11 Transportation Shipment
by Common Destination
Carrier
0 Disinterment
Date Cemetery Address
t Q Reinterment Date Cemetery Address
Permit Issued to g
Re Istration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm MakingDisposition or to Whom
�¢F P
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/21/2017- _ __ Registrar of Vital StatTsl:iCs R96ertXcUrtu -- -- - _ ElectroftkQuys=gned_-_
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains f th decedent identified above were disposed of in accordance with this permit
on:
Date of Disposition 6 2-3 7 Place of Disposition . /`11 ii e�,$l t.b CA by
7ss)�wl1
(section) (lot giber) (grave number)
Name of Sexton or rson in harge of Premises 11 h.,- f"."
(please print)
itt
Signature Z _- Title
(over)
DOH-1555(02/2004)