Williams, Marie Louise A)Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marie Louise Williams Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2020 66 Years War or Dates
II— Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
UJI
13 Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
W Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 14
Burial Date Cemetery,Crematory or Facility Name
01/29/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
Z ❑Removal Date Place Removed
pand/or —7and/or Held
-
N Hold Address
O
0. Date Point of
to �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
: II— Remains are Shipped,If Other than Above
2 Address
Ix
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/29/2020 Registrar of Vital Statistics Caro1,'w-Wdk,4ard--0arAer(i&trOnuaQySywq)
(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 'I
Z Date of Disposition 1 131 110 Place of Disposition
uj /address/
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(section/ (lot number/ (grave number/
Name of Sexton or Person in Charge of remises ��Py/ L �lv�/
Z J� ase print/
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W Signature / Title A,i-s'"o
DO H-1555(o7/18)p t of 2
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Public Health Law Sec. 4145(2b) 3 2 i
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '
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