Kaufman, Fay �2°
NEW YORK STATE DEPARTMENT Or'HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Fay Eileen Kaufman Female
Date of Death Age If Veteran of U.S. Armed Forces,
• 12/01/2017 79 Years War or Dates
€.. Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death X Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Blood MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
e. Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 152
_ ❑Burial Date Cemetery or Crematory
12/04/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
1-1❑Removal and/or Held
and/or
Address
Hold
Date 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 12/01/2017 Registrar of Vital Statistics Caroline J{Bar6er Efectronicaffy Signed'
=ma's (signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition iti s In Place of Disposition I U-i
(address)
(section) got number) (grave number)
Name of Sexton or Person in Charge of Premi es jI •S»-�
(p/e print) �1
Signature fNt .01 Title (Rump,
1-
(over)
DOH-1555 (02/2004)