Pincheon, Marion Francis # lilt
NEW YORK STATE DEPARTMENT OF HEALTH ` , - Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marion Francis Pincheon Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/20/2020 91 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
p Manner of Death 0 Natural Cause 1=I Accident El Homicide ❑Suicide El Undetermined ❑Pending
W U Circumstances Investigation
W Medical Certifier Name Title
0 John Quaresima MD
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 90
❑Burial Date Cemetery,Crematory or Facility Name
10/22/2020 Pine View Crematory
ElEntombment Address
E]Cremation Queensbury,New York
ElDonation
Z Removal Date Place Removed
and/or and/or Held
I- Hold Address
N
0
O. Date Point of
coTransportation Shipment
Q by Common
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
1.- Remains are Shipped,If Other than Above
S Address
EC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/22/2020 Registrar of Vital Statistics "limeeMahoney(EkctronicalySgned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F
Z Date of Disposition ►0 lit) of Disposition g ..... ifs--
2 (ad
in ress)
W
U)
CC (section) (lot tuber) (grave number)
gName of Sexton or Person in Charge of P. mises ASl ,5Ov,n4IFt
Z (please pn
W Signature C� Title G�'r'"rl��
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 1 3 8
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#