Hatin, Elaine Cora . �NEW YORKSTATE DEPARTMENT OF HEALTH 21
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Elaine Cora Hatin Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/06/2020 82 Years Waror Dates
F. Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address 341 Lamplighter Acres, Fort Edward Town,New York 12828
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
V
Q Medical Certifier Name Title
Madison Zuis Np
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 3
Burial Date Cemetery,Crematory or Facility Name
01/07/2020 Pine View Crematory
Entombment Address
Rci Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
Hold Address
O
CL Date Point of
W ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
1EIReinterment Date Cemetery Address
Permit Issued to T 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
F- 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 01/07/2020 Registrar of Vital Statistics gimee-Walroney(EiYectr-n&af Srgneq)
(signature)
District Number 5755 Place Fort Edward, 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 I Zv Place of Disposition a„/ fa�:'
W
(address)
W
W (section/ t number/ (grave number)
aName of Sexton or Person in Charge of Premises �'i 1.4
Z (pleas print)
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013 18
Receipt
Human remains of r J delivered on , 20
Pine View Cemetery Representing the funeral home named on burial Permit
Official Funeral Directors Reg.or License# ,