Graham, Wanda Jean # b7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wanda Jean Graham Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/20/2021 63 Years War or Dates
p,. Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 16E Skylark Drive,Moreau Town,New York 12803
IiJ Manner of Death
0 W Natural Cause 0 Accident 0 Homicide ❑Suicide ❑Undetermined ❑Pending
U Circumstances Investigation
al Medical Certifier Name Title
Anne Evans DO
Address
3 irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 6
0 Burial Date Cemetery,Crematory or Facility Name
01/25/2021 Pine View Crematory
❑Entombment Address
— gl Cremation Queensbury Town,New York
0 Donation
Z Removal Date Place Removed
O Eland/or and/or Held
H Hold Address
N
0
O. Date Point of
f/) Li 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
E... Remains are Shipped,If Other than Above
5 Address
Q
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/22/2021 Registrar of Vital Statistics Geeanngfc cage(Ekctrorricall'Signed)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permi •
H
Z Date of Disposition r llS 171 Place of Disposition L.I. ,�.----
W
2 (address)
W
U)
CC (section) yrt number) [ (grave number)
• Name of Sexton or Person in Charge of Pre .ses1 t,f L, �i.�x.�f�
Z (please print)
W Signature Title � " 0,_
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of y' delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#