McCabe, Jane tk )
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane McCabe Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/13/2021 100 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
ILI
0 Manner of Death Undetermined Pending
W g Natural Cause Accident ❑Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title
O Jennifer Donovan DO
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 15
Burial Date Cemetery,Crematory or Facility Name
01/19/2021 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
Donation
O• ElRemoval Date Place Removed
and/or and/or Held
F- Hold Address
0
a 1-1 Date Point of
t/) ❑Transportation
p by Common Shipment
Carrier Destination
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
Address
W
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/15/2021 Registrar of Vital Statistics Carmine igarde Barb-er(Electrvnical51,*ne4
(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:
Z Date of Disposition /Zd 17I Place of Disposition
2 (address)
W
N (section) t number) (grave number)
_ L 0 Name of Sexton or Person in Charge of Pre ises °'`
Z (pleas0print)
W Signature `� Title `iL�+`W71
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
J14427
Receipt
Human remains of delivered on ' , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#