Sabayrac, Marilyn •
St 103ill
NEW YORK STATE DEPARTMENT OF HEALTH �_ ItBurial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Marilyn June Sabayrac Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/28/2018 74 Years War or Dates
,' Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Ed Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Maria Vivenzio DO
Address
• 211 Church St,Saratoga Springs,New York 12866
=, Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 680
Av
��['Burial
Date Cemetery or Crematory
12/31/2018 Pine View Crematory
❑Entombment Address
t v Cremation Queenshury Town, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
e x'`
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
4..; Date CemeteryAddress
1'Q Disinterment
js Date Cemetery Address
ifo? �]Renterment
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
Remains are Shipped, If Other than Above
s Address
• Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 12/28/2018 Registrar of Vital Statistics John'P'Franck(rE(ectronicadty Signed)
(signature)
t District Number 4501 Place Saratoga Springs, New York
I4
3_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i f Z.i ll Place of Disposition ell.. ,1-jrs,,..
(address)
14
(section) (lot number) (grave number)
ho Name of Sexton or Person in Charge of Premises
ll�d•r4 L in44
(piece print
Signature Title (R + - t
(over)
DOH-1555 (02/2004)