Russell, Patsy Ray NEW YORKSTATE DEPARTMENT OF HEALTH - - r Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patsy Ray Russell I Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/22/2019 84 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Bolton Town Street Address 286 Potter Hill Road, Bolton Town, New York 12814
p Manner of Death PE Natural Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
W Medical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Bolton Landing 5650 13
Burial Date Cemetery,Crematory or Facility Name
12/30/2019 Pine View Crematory
Entombment Address
QCremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
O
a Date Point of
N ❑Transportation Shipment
p by Common
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
H Remains are Shipped,If Other than Above
2 Address
jr-
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/30/2019 Registrar of Vital Statistics 9odL Conrtaffy(E&tro-?a-5S#ned)
(signature)
District Number 5650 Place Bolton Landing, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
WDate of Disposition 12�3/_I q Place of Disposition /�rj-1 c✓7'o
2 (address)
W
W (section) (lot number) (grave number)
8 Name of Sexton or Pers in Cha of Premises J _" 1 r �
(please print)Z
W Signature Title
DOH-1555(07/18)p of 2
Public Health Law Sec. 4145(2b) 013190
Receipt
Human remains of delivered on , 20
r
!Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#