Storm, Neva NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
tt Name First Middle Last Sex
Neva Idene Strom Female
Date of Death Age If Veteran of U.S. Armed Forces,
444 09/06/2017 85 Years War or Dates
Place of Death Hospital, Institution or
CityIll , Town or Village Glens Falls Street Address Glens Falls Hospital
tp Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
13 Circumstances Investigation
0 Medical Certifier Name Title
' Michael Fuller MD
Address
100 Park St,Glens Falls,New York 12801
.
Death Certificate Filed District Number Register Number
ilq City, Town or Village Glens Falls 5601 482
❑Burial Date Cemetery or Crematory
k3.' 09/11/2017 Pine View Crematory
k.s.,':;❑Entombment
Address
®Cremation_ Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
u)❑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
4.4 Name of Funeral Firm Making Disposition or to Whom
I_ Remains are Shipped, If Other than Above
• Address
Et
W
: Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/11/2017 Registrar of Vital Statistics Ro6cnACurtis cE1 ctrouicalTySigned
(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:
z I .� ail.) r,evn or ..,
W Date of Disposition 9 �� n Place of Disposition t'n><
2 (address)
W
CO
Ce (section) A(lot number) (grave number)
pName of Sexton or Person in Charge of PremisesN,i S,Mtt�
z ' (ple se print)
Signature Title fi /n1ftr-
tr
(over)
DOH-1555 (02/2004)