Doner, Nicole Doner . t //o7
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nicole Jean Doner Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/07/2020 26 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death ❑ Natural Cause 0 Accident Ei Homicide Suicide ❑Undetermined II Pending
U Circumstances Investigation
W Medical Certifier Name Title
Timothy Murphy Coroner
Address
52 HAVILAND AVE,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 464
DiBurial Date Cemetery,Crematory or Facility Name
10/13/2020 Pine View Crematory
El Entombment Address
Cremation Queensbury Town,New York
❑Donation
4 Removal Date Place Removed
and/or and/or Held
~ Hold Address
0
d. 1-1 Date Point of
N Li Transportation
ES Common Shipment
Carrier Destination
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
l- Remains are Shipped,If Other than Above
2 Address
tC
11.1
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2020 Registrar of Vital Statistics Curtzr gkctronicaI,.5018d
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t— t(
W Date of Disposition /0/14 170 Place of Disposition y�1
(address)
W
•
CC N (section) 4 (lot numb (grave number)
Name of Sexton or Person in Charge of Premises A OttAAMI11..
ase print)
W 9 iC
Signature L—� Title l i �
DOH-1555(o7/18)p t of 2
•
s_
Public Health Law Sec. 4145(2b) 01 4099
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#