Belden, Mary Louise (
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle 1111 Last Sex
Mary Louise Belden Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2021 83 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
p Manner of Death I1 Natural Cause ElAccident 0 Homicide 0 Suicide Undetermined ElPending
W U Circumstances Investigation
W Medical Certifier Name Title
0 Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 5
EjBurial Date Cemetery,Crematory or Facility Name
01/05/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
El Donation
Zr7Removal Date Place Removed
0 and/or and/or Held
H Hold Address
CO
0
a. Date Point of
U) LI Transportation Shipment
Q by Common
Carrier Destination
0 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
f.. Remains are Shipped,If Other than Above
i Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2021 Registrar of Vital Statistics RP6ert/?ndrew Curtis(EYectronicali5Srgned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH aZ Date of Disposition I Ib/ZI Place of Disposition
UJ (addres
W
CO (section) number) (grave number)
IX
0 Name of Sexton or Person in Charge of Pr ises
Z �`
(please p t) �
7
W Signature Title llp4
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) .A 1 4 3 7 t^
op
Receipt
Human remains of delivered on , 20 •
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#