Ibanez, Mary NEW YORK STATE DEPARTMENT OF HEALTH I , ! 33
Vital Records Section Burial - Transit Permit
Name First Middle LOU. Last Sex
Mary L-ae Ibanez Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/02/2012 77 years War or Dates
1. Place ot ueathHospital, Institution or
LLICity, Tov XV -9.i X Clcns Fa Street Address Clcns Is ILoc ital
Manner o eat Natural Cause Accident ❑Homicide ❑Suicide n e ermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
Add ess k Smith M D
G F Hospital 100 Park St. Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Tow rXV� (X Glens Falls 5601 319
['Burial ate Cemetery or Crematory
❑Entombment 07/02/2012 Pine View Crematorium
Address
❑cremation •
Queensbury, NY 12804
Date Place Removed
3 Removal and/or Held
❑and/or
Address�; ;;
V
Hold
4 Date Point of
t#❑Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
B.❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Permission is hereby granted to dispose of the human remains described above.as indicated.
Date Issued 07/02/2012 Registrar of Vital Statistics W ok," .4). -r
(sign ure)
District Number Place �7
5601 Glens Fads, N Le I b 6
I certify that the remains of the decedent identified above were disposed of in accordance"with this permit on:
k
ill Date of Disposition 7131J2 Place of Disposition ,P,,,.(�,4" 6640r,.�
2 (address)
in
to
c (section) A (lot number)- (grave number)
Name of Sexton or Person in Chargeof Premises i Nli.�tir rhwl}
2► (please print)
ii Signature 7 Imo- Title CrMpult
It
(over)
•
DOH-1555 (02/2004) •