Vaccaro, Anne t 11 717
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
• Anne Marie Vaccaro Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/22/2017 70 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Blood MD
t. Address
- 100 Park St,Glens Falls,New York 12801
1 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 547
if,❑Burial
Date Cemetery or Crematory
10/24/2017 Pine View Crematory
r 15
❑Entombment Address
®Cremation Queensbury Town, New York
'4i Date Place Removed
0 Removal and/or Held
and/or Address
f. Hold
P
AI Date Point of
Q Transportation Shipment
}
: by Common Destination
Carrier
Disinterment Date Cemetery Address
7,- -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
- Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/24/2017 Registrar of Vital Statistics 4,6enACurtzs E(euronwartys'gref
(signature)
District Number 5601 Place Glens Falls, New York
av
a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition /o 41111 Place of Disposition 1 AtV✓ Gr c1°'---
(address)
(section) /� (lot number) (grave number)
Pe
`�
Name of Sexton or Person in Charge of P emises ''"it" J 1.
(p se print)
. 4 Title P�.na4..
,� Signature
(over)
DOH-1555 (02/2004)