Low, Hope 1
NEW YORK STATE DEPARTMENT OF HEALTH;
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hope Hesselfelt Low 4i, -,`- Female
04,
4. Date of Death Age If Veteran of U.S. Armed Forces,
05/14/2018 28 Years War or Dates
Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death rig NaturalCause 0Accident 0Homicide 0 Suicide �Undetermined �Pending
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Circumstances Investigation
'� Medical Certifier Name Title
Mathew Varughese DO
14 Address
100 Park St,Glens Falls,New York 12801
it
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 241
• Burial Date Cemetery or Crematory
41 05/17/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
k and/or
R Address
Hold
Date Point of
Q Transportation Shipment
• by Common Destination
ki Carrier
Q Disinterment Date Cemetery Address
Q 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
¢. Remains are Shipped, If Other than Above
.R Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/17/2018 Registrar of Vital Statistics We6ertA Curtis(ECectronicaftySigned)
(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:
Date of Disposition slisjli? Place of Disposition ?�U� i2r
(address)
'" (section) /lot number)_ (grave number)
Name of Sexton or Person in Charge of Premises (pese print)
Signature tit fr Title "
(over)
DOH-1555 (02/2004)