Henckel Miram Agnes 4M
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Miriam Agnes Henckel Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/21/2020 86 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
`p Manner of Death ❑X Natural Cause Accident Homicide 1:1Suicide Undetermined Pending
Circumstances Investigation
W 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 91
Burial Date Cemetery,Crematory or Facility Name
02/24/2020 Pine View Crematory
Entombment Address
JC Cremation Queensbury Town, New York
Donation
ZORemoval Date Place Removed
and/or —7and/or Held
F-
asHold Address
O
a Date Point of
N Transportation
p by Common Shipment
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
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/24/2020 Registrar of Vital Statistics Wp6ertJ?ndrewCurtu(''Eketronicad Siyiwd�
(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:
F
Z Date of Disposition 2 1 ZS TO Place of Disposition s i�.--
t!J address)
2
W
N (section) lit
lot number/ (grave number)
QName of Sexton or Person in Charge of Prem s P'
Z (piea a print)
LU Signature Title
DO H-t555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) J 4
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# `