Eddy, Jarmilla # 3t8
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jarmilla Maria Eddy Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/13/2018 82 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death fJ Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 233
['Burial Date Cemetery or Crematory
05/14/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date fF Point of
❑Transportation Shipment
by Common Destination
Carrier
❑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
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/14/2018 Registrar of Vital Statistics RobertA Curtis(E(ectronicat[y Signed)
(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 C f l4 I lq Place of Disposition ?µtiA, /ry„ ,T,�
(address)
(section) 41(lot number) (grave number)
Name of Sexton or Person in Charge of remises `nt((''^' S... lt
(ple"ase print)
Signature 'mil Title (ONTAt
(over)
DOH-1555 (02/2004)