Sandburg, Karen Louise NEW YORKSTATE DEPARTMENT OF HEALTH - # Z%
Bureau of Vital Records - Burial - Transit Permit
Name First Middle Last Sex
Karen Louise San dbur --T- Female
Date of Death F76
ge If Veteran of U.S.Armed Forces,
03/29/2020 Years War or Dates
�... Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
W C.) Circumstances Investigation
LU Medical Certifier Name Title
93 Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District gister N
Number Reumber
City,Town or Village Glens Falls 5601 146
Burial Date Cemetery,Crematory or Facility Name
03/31/2020 Pine View Crematory
-- Entombment Address
nCremation Queensbury Town, New York
Donation
0 ❑Removal Date Place Removed
F= and/or and/or Held
Hold Address
O
a Date Point of
N 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 orto Whom
H. Remains are Shipped,If Other than Above
Address
fu
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/31/2020 Registrar of Vital Statistics `RQ6zt/4naAewCurtu(E&tmnwaf Signeq)
(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:
H U
Z Date of Disposition 7�1 �Zp Place of Disposition {
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(address)
W
U)
(section) (/otnumb _ (gravenumber)
O Name of Sexton or Person in Charge o remises dr'-)
Z ( ease nt/
to Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 013491
Receipt
Human remains of '_--delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#