Weidner, Mary Jane t
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Jane Weidner Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/09/2020 97 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 71 Longview Drive Apt.171,Queensbury Town,New York 12804
W Manner of Death Undetermined Pending
W Natural Cause Accident ❑Homicide El SuicideEl
Circumstances Investigation
WMedical Certifier Name Title
Robert Love MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 41
Burial Date Cemetery,Crematory or Facility Name
03/12/2020 Pine View Crematory
Entombment Address
517 Cremation Queensbury Town, New York
Donation
z Removal Date Place Removed
and/or and/or Held
H rn Hold Address
O
d Date Point of
to �Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment I 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
Remains are Shipped,If Other than Above
Address
W
CL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2020 Registrar of Vital Statistics CaroCtneSYd-degard Bar&r(Ek-ntronicaTy,Synea)
(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:
W Date of Disposition -/tf�p�U Place of Disposition e
(add
W
N (section) (/ot nu ber) (grave number)
Name of Sexton or Person in Cha of Pre i s �� Gt�
Z (please print)
W �
Signature �' Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 013428
Receipt
Human remains of delivered on , , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#