Brindzak, Shirley V. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley V.Brindzak Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/19/2019 101 Years War or Dates
E... Place of Death Hospital,Institution or
Z City,Town or Village Saratoga Springs Street Address Wesley Health Care Center Inc
W
p Manner of Death Ri Natural Cause 1:1Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
Brittany Miske NP
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 611
Burial Date Cemetery,Crematory or Facility Name
11/19/2019 Pine View Crematory
Entombment Address
1 Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
U) Hold Address
U)
O
G. Date Point of
U) ElTransportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
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
2
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/19/2019 Registrar of Vital Statistics )nlrn Pau,(Fhanck(E&tmnicaffySrgned)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t—
WDate of Disposition U ( Place of Disposition
,Uj (address)
W
U) (section) t number) (grave number)
�S h(Name of Sexton or Person in Cty�rge of Premises
Z //, (plea a print)
W Signature '^'l Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) " " 01309
Receipt
Human remains of r delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#