Guay, Clara 6 - ( - 77
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clara Ann Guay Female
Date of Death Age If Veteran of U.S. Armed Forces,
' 02/23/201h1 67 years. War or Dates
P. o eat Hospital, Institution or
E City, o,. .5(V - Street Address
t .� Glens Fa Glens Fall N Y 12801
er o yea �� Natural Cause Accident ❑Homicide ❑Suicide ❑undetermined ID Pending
ilk Circumstances Investigation
to Medical Certifier Name Title
0
Hoffman M. D.
Add ess
420 Glen Street Glens Falls, NY 12801
Mi - _ Certificate Filed District Number Register Number
V,. oxyabe X Glens Falls 5601 Al
lillili II :.vial ate Cemetery or Crematory
ilili ❑Entombment 2/24/2011 Pirieview Crematory
Address .
Cremation •
Queensbury, QI Y 128n4
Date Place Removed
Z❑Removal and/or Held
and/or Address
Cl)
Hold -
0 Date Point of
ti❑Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
iiiiiiii Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01149
Address
11 i afayPtte Street Oueenshury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
lI
cL
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/24/2011 Registrar of Vital Statistics C,ur--s .t, ,r-, '
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 61s-1 20l( Place of Disposition (� t
2 (address)
in
CC (section) 4 _ (lot number) (grave number)
0
�-
Name of Sexton or Person in Charge of remises r.stee Sar�tlt"
/ -� (please print)
Signature C Title rvEitI1i-I`oq
(over)
DOH-1555 (02/2004)