Stevenson, Connie Lyne �-7c
A.
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Connie Lyne Stevenson Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/19/2019 52 Years War or Dates
II... Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 5 Wincrest Drive,Queensbury Town,New York 12804
WW Manner of Death Undetermined Pending
Q Natural Cause �Accident �Homicide �Suicide � � g
C.) Circumstances Investigation
W Medical Certifier Name Title
Colleen Quinn MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 171
Burial Date Cemetery,Crematory or Facility Name
11/20/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
� Date Place Removed
❑Removal
and/or and/or Held
f-CA Hold Address
O
IL Date Point of
CO) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
JE]Reinterme�� 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
Q
W
I' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/20/2019 Registrar of Vital Statistics CaroCire-W,-fd2,4arde Bader(E&--'ronicaffySymde
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition //-20-/9 Place of Disposition P VrC Ld (i/�.
U) (address)
2
W
CO) (section) (lot number) (grave number/
O Name of Sexton or Person i C e Premises
(please print)
Z
W Signature Title 2 m °i
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013 Q S16
Receipt
Human remains of delivered on , 20
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
i
I
I
Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of: Connie Lyne Stevenson
were cremated on November 20 20 19 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death November 19 2019 Age 52
(Month) (Day)
Funeral Home Maynard D. Baker Funeral Home Registered No. 771
(A#rized Signature)
NAME Connie Lyne Stevenson Age: 52
Lot Owner: Earl Harrington
Lot# 2 5 A Grave# 3 B
Case: URN LJ OQL- LLG
Died: 1 1 /1 9/1 9 Interred: 1 2/6/1 9
Funeral Home:
Baker Funeral Home
Cemetery:
Pine View Cemetery