Storm, Madeline NEW YORK STATE DEPARTMENT OF HEALTH 4 ti v
Vital Records Section Burial - Transit Permit
3 Name First Middle Last Sex
1, Madeline Storm Female
R Date of Death Age If Veteran of U.S. Armed Forces,
01/21/2018 78 Years War or Dates
Place of Death Hospital, Institution or
gCity, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause ❑Accident ElHomicide El Suicide ❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Marvin Davidowitz MD
Address
:, 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 44
❑Burial Date Cemetery or Crematory
01/24/2018 Pine View Crematory
;: ❑Entombment Address
1.;'®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
17 Hold
Date Point of
1' El Transportation Shipment
by Common Destination
i:: Carrier
`;'❑Disinterment
Date Cemetery Address
r Date Cemetery Address
❑Renterment
Permit Issued to Registration Number
14
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
Remains are Shipped, If Other than Above
Address
CC
Ili
d' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2018 Registrar of Vital Statistics co6ertA Curtis(ECectronica1ty Signed)
:' (signature)
District Number 5601 Place Glens Falls, New York
A
lF I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition //2 (Ig Place of Disposition -PZ,J.., e
(address)
46
(section) Allot number (grave number)
itt
Name of Sexton or Person in Charge of Premises ( r.4-• 4
Z (p/ ase print)
W.
Signature ' Title fkk t n pe,i1
(over)
DOH-1555 (02/2004)