Medved, Jan Susan -# 7�
NEW YORKSTATE DEPARTMENT OF HEALTH Burial Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jan Susan Medved Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2020 71 Years War or Dates
II.- Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
93 Kenneth France MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601
Burial Date Cemetery,Crematory or Facility Name
04/01/2020 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or —7and/or Held
i-to Hold Address
O
IL Date Point of
to 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
1.- Remains are Shipped,If Other than Above
Address
c
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/01/2020 Registrar of Vital Statistics Tp6enf7ndrewCunrs(EketronicaffySozed�
(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 P�
Date of Disposition ��Z I Zf, Place of Disposition �,.� CJf,v
W (address)
W
N (section) Alot number (grave number)
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C Name of Sexton or Person in Charge of Pre i s r
(p ease print)
W Signature Title
DO H-1555(07/18)p 1 of 2
a
Public Health Law Sec. 4145(2b) 0 1 3 4 N
Receipt
Human remains of
delivered on , 20
Pine View Cemetery Representing the funeralhome named,on..burial permit
Official Funeral Directors Reg.or License#