Carlsen, Helen Ann 17 11
NEW YORK STATE DEPARTMENT OF HEALTH Transit it
Bureau of Vital Records Burial - Transit
Name First Middle Last Sex
Helen Ann Carlsen Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/29/2020 84 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
Manner of Death ID Natural Cause El Accident I=1 Homicide El Suicide El Undetermined El Pending
O Circumstances Investigation
W Medical Certifier Name Title
O Leonard Gelman MD
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5756 79
ElBurial Date Cemetery,Crematory or Facility Name
12/01/2020 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town,New York
ElDonation
O El Removal Date Place Removed
and/or and/or Held
}- Hold Address
0
D. Date Point of
(i) ❑Transportation
0 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
ElReinterment 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
g Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/01/2020 Registrar of Vital Statistics Jenny Litt1affanelle(E/ctronica*Signed)
(signature)
District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IE—
WDate of Disposition l a/ Zo Place of Disposition -to Cam..
2 (address)
W
CC N (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Pre
(p/ se print)
14
n
W Signature Title /r (7Rc,
DOH-t555(07/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# _.