Osterhout, Evelyn J
NEW YORK STATE DEPARTMENT OF HEALTH r k �i
Vital Records Section ,. , Burial - Transit Permit
Name First Middle Last Sex
t Evelyn E.Osterhout Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/28/2017 83 Years War or Dates
Place of Death Hospital, Institution or
Hospital
Hos i
City, Town or Village Glens Falls Street Address Glens Falls
Y 9 p
Manner of Death Natural Cause El Accident 0 Homicide El Suicide El Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Bergin DO
Address
100 Park St,Glens Falls,New York 12801
ti Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 559
❑Burial Date Cemetery or Crematory
z 10/31/2017 Pine View Crematory
4 U Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
= ..` ❑Removal and/or Held
and/or Address
Hold
Date Point of
-`¢ Q Transportation Shipment
by Common Destination
',,{ Carrier
-0,,vz
A Date Cemetery Address
f Q Disinterment
. ❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
3 11 Lafayette St,Queensbury,New York 12804
' '', Name of Funeral Firm Making Disposition or to Whom
'' Remains are Shipped, If Other than Above
Address
.v Permission is hereby granted to dispose of the human remains described above as indicated.
Y
Date Issued 10/3t/2047 Registrar of Vital Statistics 44,fiert A Curtis
74,
(signature)
District Number 5601 Place Glens Falls, New York
ii
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
j` Date of Disposition /f )2 IO Place of Disposition 'Cult i `,,,,.,r4.^-
(address)
(section) A (lot number) (grave number)
Name of Sexton or Person in Charge of Premiss 64,, number)",
lease print)
r'
Signature G^ b- Title [fg#42
(over)
DOH-1555 (02/2004)