Szewczyk, Marna Pirlar -k ;
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marna Pirlar Szewczyk Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/15/2020 70 Years Waror Dates
F- Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 721 Moon Hill Road,Queensbury Town, New York 12804
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
0 Medical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 46
❑Burial Date Cemetery,Crematory or Facility Name
03/18/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
~ Hold Address
0
C- Date Point of
t/) 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
f— Remains are Shipped,If Other than Above
Address
cc
W
G" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/18/2020 Registrar of Vital Statistics Carolne9f�garde Bar6er(!Electronka-5Signed�
(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
W Date of Disposition 3`/ -Zo2v Place of Disposition ;�Ve ,�
tu (addr
w
(section) (lot number) (grave number)
CName of Sexton or Person in Charge of Premiss
Z (please print)
W Signature Title
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4f45(( b) 0134,10
Receipt
Human remains of 1, ' ' y, Y delivered on , 20
,t
6ife iew Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
F