Martin, Theresa NEW YORK STATE DEPARTMENT OF HEALTH
# Z1
Vital Records Section ,o Burial - Transit Permit
Name First Middle Last Sex
Theresa Faith Martin Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/04/2011 83 years War or Dates
it P e of Death Hospital, Institution or
F Ci owr�gr�yillaogXX Glens Falls Street Address Park St Glens Falls. N Y 12801
Inner of Death 0 N,ptural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
to Circumstances Investigation
tij Medical Certifier Name Title
Amy Hogam- Moulton M. D.
Address
102 Park Street Glens Falls, N Y 12801
D-ath Certificate Filed District Number Register Number
>` 1 owrx illR X Glens Falls 5601 261
gi ❑Burial Date . Cemetery or Crematory
❑Entombment 06/06/2011 Pineview Crematory
Address
: ;pCipmation Queensbury, N Y 12804
Date Place Removed
❑
Removal and/or Held
and/or
Address�;;;
to
Hold
{; Date Point of
i Transportation Shipment
a 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 01149
iffi Address
110 11 Lafayette Street Queensbury, N Y 12804
ailli Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr.
til
Permission is hereby granted to dispose of the human remains described above s i icat
Date Issued 06/06/2011 Registrar of Vital Statistics , f4
iiiiii
(signature)
IN District Number 5601 Place Glens Falls /k/ /p2 aU/
it I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition t.^%-tt Place of Disposition -r,0,,t..tw Circe^-tii dt1uY..
(address)
tli
to
cc (section) (lot number (grave number)
Name of Sexton or erson in Charg of Premises r.,,i ' e`,
2 (please print)
Lii Signature Title Cats i�f}toL-
(over)
DOH-1555 (02/2004)