Gelina, Carol Diane NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carol Diane Gelina Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/19/2020 73 Years War or Dates
i—, Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Mannerof Death � Natural Cause ❑Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 135
Burial Date Cemetery,Crematory or Facility Name
03/25/2020 Pine View Crematory
Entombment Address
ICremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
O and/or and/or Held
~ Hold Address
N
O
IL Date Point of
W 0 Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
�interment 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 orto Whom
Remains are Shipped,If Other than Above
Address
IIM
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/25/2020 Registrar of Vital Statistics &&&,4ndrewCurtu(ElectronicafSigned
(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-
W
p
Date of Disposition 3—ZG—=pzPlace of Disposition v 1Gr 'e-4
LU (address)
W
N (section) (lot number) (grave number)
IQ
Name of Sexton or Person in Ch a of Premises fia
(please print)
Z -for
W Signature S Title
I
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b) 013467
Receipt
Human remains of } r ,r delivered on , 20'
Pine view Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#