Anderson, Mary Josephine NEW YORKSTATE DEPARTMENT OF HEALTH : Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Josephine Anderson Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/28/2020 89 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death Natura[CauseUj Accident Homicide Suicide E]Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 57
Burial Date Cemetery,Crematory or Facility Name
03/30/2020 Pine View Crematory
Entombment Address
RCremation Queensbury Town,New York
Donation
Date --jPlace Removed
/or Held
O Removal
and/or and
F- Hold Address
N
O
d Date Point of
U) 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
H Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/30/2020 Registrar of Vital Statistics Carolne.9f�garde Bar6er(EYectronicalfySW-ed�
(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
WDate of Disposition N I Zb Place of Disposition , CWI
Uj (address)
W
N (section) (lot number) (grave number)
0
Name of Sexton or Person in Charge of remises
� (p ase print/Z
W Signature Title
DO H-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) s f J.3 4 8 9
Receipt
i
Human remains of + ' delivered on - , 20`
x fr• s
Pine View Cemetery Representing the funeral home named oilburial permit
Official Funeral Directors Reg.or License#
4
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