Guimond, Claire Arlene • „�J er?
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Claire Arlene Guimond Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/24/2021 82 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
`p Manner of Death Ii Natural Cause ❑Accident El Homicide El Suicide LiUndetermined 11 Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 32
ElBurial Date Cemetery,Crematory or Facility Name
01/26/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
02 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
n• Date Point of
U3 ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El 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
5 Address
CC
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2021 Registrar of Vital Statistics Carolinex4gard Barger(Ekctronica/l'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:
W Date of Disposition I '7$ili Place of Disposition
IL4
2 (address)
W
N CC (section) 4 (lot number) (grave number)
/
0 Name of Sexton or Person in Charge of Premise `' t.,'hpL ^i'tt
z
Z (p ase print)
W eNti
Signature Title firVQ
DOH-1555(07/18)p 1 of 2
3
Public Health Law Sec. 4145(2b) 1." "
Receipt
Human remains of delivered on , 20 ;;
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#