Fuller, Mary Pig
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Louise Fuller Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/26/2014 81 years War or Dates
Place of Death Hospital, Institution or
Z City, TowXxjdiIXX Glens Falls Street Address 440 Glen Street Apt#1 Glens Falls, NY 12801
Manner of Death fflkatural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Anthony Petracea M D
Address
3 Irongate Plaza Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TowXX X'iI XX Glens Falls 5601 405
❑Burial Date Cemetery or Crematory
❑Entombment 08/27/2014 Pine View Crematorium
Address
2/Cremation Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
Hold
Cl)
0 Date Point of
0 Li Transportation Shipment
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 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Ir. Remains are Shipped, If Other than Above
2 Address
cr
CL
tLJ
Permission is hereby granted to dispose of the human remains descri ed above in t d.
Date Issued 08/27/2014 Registrar of Vital Statistics Lil
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition g/2rhi Place of Disposition
(address)
Ul
CC (section) (lot number) (grave number)
laName of Sexton or Perso in Char a of Premises A.)fi SnWI!
(plelase print)
Signature Title C 'hidrL
(over)
DOH-1555 (02/2004)