Tierney, Patricia . N
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Patricia Jane Tierney Female
Date of Death Age If Veteran of U.S. Armed Forces,
'' 01/12/2018 83 Years War or Dates
44 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Lit Medical Certifier Name Title
0 Courtney Stewart NP
Address
r 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 21
i:fr,®Burial Date Cemetery or Crematory
01/19/2018 Pine View Cemetery
❑Entombment Address
- ❑Cremation Queensbury Town, New York
Date Place Removed
I❑Removal and/or Held
and/or Address
to Hold
Date Point of
• ❑Transportation Shipment
• by Common Destination
Carrier
`❑Disinterment Date Cemetery Address
▪L ❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
• Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
d Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/16/2018 Registrar of Vital Statistics &o6ertA Curtis(E(ectronicafy Signed)
(signature)
▪ District Number 5601 Place Glens Falls, New York
• I certify that the remains of the decedent identified above were isposed of. accordance with this permit on:
I t Date of Disposition /l i Val Place of Dispositio 2 i g i2h.� )C QLt ,( IUL , .
(address)
1 �3_ Lc- s.
(sectioit � (lot number) (grave number)
Name of Se or Person in Char a of Premises l�d/c9I� C-- �EbA--
r; D �) (p a print)
,, Signature �u't P ^ ' Ce�� Title
(over)
DOH-1555 (02/2004)