Haskoor, Shirley V
NEW YORK STATE DEPARTMENT OF HEALTH B rial Transit Permi
Vital Records Section 4 u - t
Name First Middle Last Sex
Shirley May Haskoor Female
V Date of Death Age If Veteran of U.S. Armed Forces,
12/22/2017 94 Years War or Dates
LewPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause El Accident El Homicide El Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski DO
JR Address
-,- 100 Park St,Glens Falls,New York 12801
r Death Certificate Filed District Number Register Number
;,` City, Town or Village Glens Falls 5601 668
" <OBuriai Date Cemetery or Crematory vr
Al 12/26/2017 Pine View Crematory
Al
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
f, Removal
and/or Held -
and/or Address
Hold
Date Point of
L]Transportation Shipment
am
w.., by Common Destination
Carrier
rot
Disinterment Date Cemetery Address
[]Reinterment Date Cemetery Address
tv 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
tee,
rli
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/26/2017 Registrar of Vital Statistics qt9bertA cum VearonicallySignei(
(signature)
ktki District Number 5601 Place Glens Falls, New York
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition l2/1 1 Place of Disposition ) )' ;- t) -11. -1.0,41
(address)
y
(section) of number) (grave number)
Name of Sexton or P on i Charge of Premises ..w(tom. _
(please print)
C ,e r.�- -4i.-"
Signature Title/
(over)
DOH-1555(02/2004)