VanNess, Mary Elizabeth NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Elizabeth Van Ness Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/09/2021 89 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 52 Pinello Road,Queensbury Town,New York 12804
W Manner of Death Undetermined Pending
G M. Natural Cause Accident Homicide Suicide
W
U Circumstances Investigation
W Medical Certifier Name Title
CI Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 9
Burial Date Cemetery,Crematory or Facility Name
01/12/2021 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
o ElRemoval Date Place Removed
and/or and/or Held
t- Hold Address
O
O. Date Point of
co 1-1
Transportation
O by Common Shipment
Carrier Destination
El
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
H Remains are Shipped,If Other than Above
N Address
CC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/12/2021 Registrar of Vital Statistics Carolinexklegarde Barier(Thctronicall'Signed)
(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:
2
W Date of Disposition j/IZ 1�� Place of Disposition -Poi rw✓'Fof1,��
2 (address)
W
N CC (section) ft(lotnumber) (grave number)
0 Name of Sexton or Person in Charge of Pr ises t.5 \. 0 4fi
Z (plea+print)
tL Signature Title
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 014404
Receipt
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Human remains of delivered on , 20 1
4 , kfl�
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#