Squires, Kelley Lin )qo
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kelley Lin Squires Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/02/2021 54 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Greenwich Town Street Address 138 Lowber Road, Greenwich Town, New York 12834
W Manner of Death Undetermined x Pending
W ❑ Natural Cause ❑Accident Homicide 1=1SuicideEl
Circumstances Investigation
W Medical Certifier Name Title
CI Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed District Number Register Number
City,Town or Village Greenwich 5757 3
❑Burial Date Cemetery,Crematory or Facility Name
02/05/2021 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
❑Donation
ZO ❑Removal Date Place Removed
and/or and/or Held
NH Hold Address
O
C- Date Point of
t/) LI Transportation
O 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
Remains are Shipped,If Other than Above
I Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/05/2021 Registrar of Vital Statistics Virderfy Whelan(Electronicall/Signed)
(signature)
District Number 5757 Place Greenwich, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-Z Date of Disposition O"4-2p2, Place of Disposition (+n
a 2 j f t
LU (address)
W
NEC (section) (lot number) (grave number)
G Name of Sexton or Person in Cha e of Premise I '��� D'
please print/
W Signature /� Title op
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b) 014 5 f16
Receipt
Human remains of delivered on , 20 it
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#