Mitchell, Janice Marie r
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name first Middle Last Sex
Janice Marie Mitchell Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/08/2019 80 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
VCircumstances Investigation
WW Medical Certifier Name Title
Dean Reali DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 527
Burial Date Cemetery,Crematory or Facility Name
12/09/2019 Pine View Crematory
Entombment Address
MCremation Queensbury Town, New York
Donation
ZO ❑Removal Date Place Removed
and/or and/or Held
F-N Hold Address
d Date Point of
N Transportation
p by Common Shipment
Carrier Destination
❑Disinterment Date Cemetery Address
1EIReinterment 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
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 2109/20 1 9 Registrar of Vital Statistics 46ertfgndrewCurt&(iYectronicad Syneq)
(signature/
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Date of Disposition )2/10 IH Place of Disposition ,,,, -(W
ul (address)
W
W tsection) (lot number)(� (grave number)
Q Lr ✓ Iv
O Name of Sexton or Person in Charge of Premises ��
Z /please print/
W Signature Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) 13 1
Receipt
Human remains of `_ delivered on , 20
Pine View Cemetery Representing the funeral home named.on burial permit
Official Funeral Directors Reg.or License# '