Caselli, Judith Ann 441g
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Judith Ann Caselli Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/03/2020 84 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
W• Manner of Death Undetermined Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
O Leonard Gelman MD
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 37
Burial Date Cemetery,Crematory or Facility Name
10/05/2020 Pine View Crematory
El Entombment Address
0 Cremation Queensbury Town,New York
ElDonation
pRemoval Date Place Removed
and/or and/or Held
F- Hold Address
(A
0
O. Date Point of
(I) ❑Transportation
p by Common Shipment
Carrier Destination
ElDisinterment 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
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/05/2020 Registrar of Vital Statistics Slrelley54Ickernon(?E/ctronicaly5wned)
(signature/
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z �1D—
W Date of Disposition 10'ie 1 10 Place of Disposition t,..
(ad ress)
W
CC
(section) (lot nurnbe (grave number)
Q C
D Name of Sexton or Person in Charge of P eem (p se ��(it
(p�ase print)
W Signature Title rOhiOt V
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 0 .,_A 0 7 0
Receipt
Human remains of t - . delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#