Terrell, Patricia NEW YORK STATE DEPARTMENT OF HEALTH t i 5-�
Vital Records Section Burial - Transit. Permit
Name First Middle Last Sex
Patricia Ann Terrell Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/22/2011 75 years War or Dates
)4 Place of Death Hospital, Institution or
Uj
Z City, TovyCXgpk/iX Glens Falls Street Address Park St, Glens Falls, N Y 12801
ci Manner of Death L. 01atural Cause Ej Accident 0 Homicide 0 Suicide El Undetermined 17 Pending
Circumstances Investigation
1i Medical Certifier Name Title
0 John P. Stauterburg M D
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowtogoViligoexx Glens Falls 5601 508
' >❑Burial Date Cemetery or Crematory
[]Entombment 11/28/2011 Pineview Crematory
Address
:j; ❑Qremation Queensbury, N Y 12804
Date Place Removed
❑and/or Removal and/or Held
; Address
till
0
Hold
Date Point of
ti Transportation❑ p Shipment
L by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to- Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
Permission is hereby granted to dispose of the human remains described above asandi
Date Issued 11/23/2011 Registrar of Vital Statistics .44.1. ` '141''
(signature)
District Number 5601 Place Glens Falls
<:::::<: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I!L Date of Disposition pov ty,f 2011 Place of Disposition ?nt!'u�) C f priuv-
(address)
t
t (section) 4.. (lot mplbe-r) (grave number)
CI Name of Sexton or P /son in Charg of Premises rist°jLr' Jen► t
(please print)
i t- '�
9
Snature Title (RC►4A115(L _
(over)
DOH-1555 (02/2004)