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Baxter Jan Lyn Frances
NEW YORKSTATE DEPARTMENT OF HEALTH Buriai - Transit Permit Bureau of Vital Records Name First Middle Last Sex Jan-lyn Frances Baxter I Female Date of Death Age If Veteran of U.S.Armed Forces, 02/21/2020 55 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital W Manner of Death a © Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title Shahid Ahmed MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 88 Burial Date Cemetery,Crematory or Facility Name 02/24/2020 —7Pine View Crematory Entombment Address Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or 7and/or Held ~ Hold Address N Q a. Date Point of N Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway,Fort Edward,New York 12828 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/24/2020 Registrar of Vital Statistics wpbert Andrew Curtis(Electronically Signed) (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: //�� W Date of Disposition 2171(7,0 Place of Disposition Uj /address/ W /section/ /tot number) (grave number/ Name of Sexton or Person in Charge o Premises /ple a print) Z W Signature Title DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) - J. Receipt Human remains of > delivered on , 20 Pine View cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#