Huestis, Barbara -7 NEW YORK STATE DEPARTMENT OF HEALTH + > li L1 vl
Vital Records Section Burial - Transit Permit
Name Firs Middle Last Sex
arbara Ann Huestis Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/24/2012 64 years War or Dates
Place of Death Hospital, Institution or
113`X9 own or IMP( Clifton Park Street Address Schuyler Ridge Rhc
10-
a Manner of Death R Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
0
ig Medical Certifier Name Title
1 Donald Jue Physician
Adddres
2001 Fifth Ave., Troy, Ny 12180 •
Death Certificate Filed District Number Register Number
own or 41iX Clifton Park 4552 93
= i ❑Burial Date Cemetery or Crematory
09/25/2012 Pine View Crematory
:1M 0 Entombment Address
;` ['Cremation Queensbury, N Y
Date Place Removed
g El Removal and/or Held
and/or
Fio Address
I
Hold
0 Date • • Point of
ti El Transportation Shipment
is by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Mii
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker 01130
Address
11 Lafayette St., Queensbury, Ny 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
"' Permission is hereby granted to dispose of the a sins dj_es bed ove as' d' .
giiR Date Issued 09/24/2012 Registrar of Vital Sta ti
(signature)
illi District Number 4552 Place Clifton Park
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to
2 �
Iti Date of Disposition 9(ZS fi Z, Place of Disposition �C,al ui (,Nivudzd fji r--
2 (address)
Lu
U)
CC (section) _ (lot number) .� (grave number)
ci Name of Sexton or P rson in Cha a of Premises (�hr*� �"�"�fT
z (please print)
Signature C2
Title c -o(
(over)
DOH-1555 (02/2004)