Lee, MaryAnn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
ym Name First Middle Last Sex
Mary Ann Lee Female
Date of Death Age If Veteran of U.S. Armed Forces,
06 / 15 / 2018 90 War or Dates N/A
}' Place of Death Hospital, Institution or
City, Town or Village Milton Street Address Gateway House of Peace
a Manner of Death Natural Cause 0 Accident E Homicide E Suicide �Undetermined �Pending
%Li Circumstances Investigation
la Medical Certifier Name Title
Lisa M. Armac FNP
Address
319 South Manning Blvd. , Albany, NY 12208
Death Certificate Filed District Number , +t s to 1 Register Number 30
City,Town or Village Milton `-
'OBurial Date I Cemetery or Crematory
06 / k9 / 2018 Pine View Crematory
rj Entombment Address
Cremation Queensbury, NY
.ii Date Place Removed
4 El❑Removal and/or Held
and/or Address
3129 Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Ziii
<< Q Reinterment Date Cemetery Address
si< Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. , Saratoga Sp., NY 12866
• Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
Address
Ir
titi
Permission is hereby granted to dispose of the hum.draL, described, :,:gg..,as indicated.
Date Issued Co I\c' \vt, Registrar of Vital Statistic t ' i IP OM
p`j� (signature)
District Number "1 Place Milton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
111 Date of Disposition (0111 lig Place of Disposition P,, tri,.4.,....
(address)
ill
fa
CC (section) (lot umber) (grave number)
aName of Sexton or Person ill Charge of Premises . (, 0.-- _s e...
► A (pleaseprint) •
ma
Signature Title p rv>L
4 .
(over)
DOH-1555 (02/2004)