Piper, Deborah NEW YORK STATE DEPARTMENT OF HEALTH 4 It
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deborah Jean Piper Female
s< Date of Death Age If Veteran of U.S. Armed Forces,
12/14/2012 56 years War or Dates
1 Place of Death Hospital, Institution or
ii City, TowDooki/i X Glens Falls Street Address 101 Broad Street 1st Floor
o Manner of Death❑�1atural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
tgi Medical Certifier Name Title
Michael Adams M. D.
Address
1448 Route 9, South Glens Falls, NY 12803
Death Certificate Filed District Number Register Number
City, Tow.(1 kVi XX Glens Falls 56o1 574
❑Burial Date • Cemetery or Crematory
❑Entombment 12/17/2012 Pine View Crematorium
Address
Pi❑Qremation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address�
Hold
Date Point of
t EI Transportation Shipment
ciby Common Destination
Carrier
El Disinterment Date Cemetery Address
iiik ❑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
g." Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
try
L
1. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/17/2012 Registrar of Vital Statistics
(sig aturMi
e)
District Number 5601 Place Glens Falls
Lii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 3'
I Date of Disposition it►/-11 Place of Disposition ' tJii,0 6cm/toct0rt_
(address)
tli
IC (section) n (lot number) (grave number)
0
Name of Sexton or Person in Charge of Premises Scnr�(t
(pl se print)
Signature d,r1L, Title CQtstidi4.,
(over)
DOH-1555 (02/2064)