Grassick, Gladys16,4Z
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last
Sex
Gladys Virginia Grassick
I Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/07/2019
85 Years
War or Dates
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Place of Death
Hospital, Institution or
City, Town or Village Glens Falls
Street Address Glens Falls Hospital
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Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
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0Circumstances
Investigation
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Medical Certifier Name Title
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William Cleaver MD
Address
100 Park St, Glens Falls, New York 12801
Death Certificate Filed
District Number
Register Number
City, Town or Village Glens Falls
5601
432
Burial
Date Cemetery, Crematory or Facility Name
Entombment
10/08/2019 Pine View Crematory
Address
0 Cremation
Queensbury Town, New York
Donation
Removal
Date
Place Removed
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and/or
and/or Held
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Hold
Address
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IL
Date
Point of
to
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Transportation
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
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Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/08/2019 Registrar of Vital Statistics Ro6er"ndrewCurt&�_'lectrvnicalySigne)
(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:
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of Disposition 10 19111 Place of Disposition
(address)
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(section) %�l (lot number) (grave number)
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Name of Sexton or Person in Charge of Premises
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/pl se print)
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Signature z Title
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Vr1RK CTATP nr:PARTMFAITnr: WPAI TN
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral hon% named on burial permit
Official Funeral Directors Reg. or License