Fawcett, Kathe Ann • y # 113C
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathe Ann Fawcett Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/15/2020 73 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death ❑X Natural Cause 11Accident El Homicide El Suicide El Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 474
❑Burial Date Cemetery,Crematory or Facility Name
10/19/2020 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
O• ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
t!)
0
O. Date Point of
co Li Transportation
Q by 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
F.. Remains are Shipped,If Other than Above
2 Address
llt
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/19/2020 Registrar of Vital Statistics `Rp6ertfgnirew Curtis(Eketronical5Srgned2
/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:
Z G�O Date of Disposition Ib/i'j 1 ZO Place of Disposition
address)
IllJ
N /section) (lotnumbe� (grave number)
CC
0 Name of Sexton or Person in Charge of Premises 4111
Zolease print)
Iw Signature .( Title (enrol
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ' J 1412
Receipt
Human remains of delivered on , 20 •
Pine View Cemetery Representing the funeral home named on burial ;. ii
Official Funeral Directors Reg.or License# -