Eddy, Mary itt S Ll
4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary K.Eddy Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/23/2018 104 Years War or Dates
Place of Death Hospital, Institution or
Z. City, Town or Village Saratoga Springsilia Street Address Wesley Health Care Center Inc
p Manner of Death 0 Natural Cause ❑Accident ❑Homicide 0 Suicide ri I'—'Undetermined ❑Pending
Ul Circumstances Investigation
{ Medical Certifier Name Title
Eric Santell NP
Address
131 Lawrence St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 57
❑Burial Date Cemetery or Crematory
01/23/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
8❑Removal and/or Held
and/or Address
5 Hold
0 Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
i, 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
a Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/24/2018 Registrar of Vital Statistics John 2'cFranckgrectronicatfy Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition f-ZS-/0 Place of Disposition ,P,) Q J u) '-f4- 'vIy
(addressr
>l
C (section) ` (lot nu er) (grave number)
3 Name of Sexton or s in Charge of Premises J Lt-/1 c-vl 7'.- '1li-riit.�
z (please print)
al .f
Signature r Title C e mG-"/e/
(over)
DOH-1555 (02/2004)