Hall, Virginia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia Josephine Hall Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/09/2018 88 Years War or Dates
Place of Death Hospital, Institution or
h•" City, Town Or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Manner of Death J Natural Cause Accident ❑Homicide ❑Suicide Undetermined 1-1 Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 25
❑Burial Date Cemetery or Crematory
02/13/2018 Pine View Crematory
DEntombment Address
®Cremation Queensbury Town, New.York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑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 St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/13/2018 Registrar of Vital Statistics Carofine7f Barber(E1ectronica[CySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition,,- i6-I? Place of Disposition Pr-. rci"cr-tor y
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises J e,f r„c.?' Sf f<s
(please print)
J
Signature/Al43A, ' Title cre-,mk}cr
(over)
DOH-1555 (02/2004)