Hitchcock, Shirley Ernestine t I(D
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley Ernestine Hitchcock Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/28/2021 81 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address Slate Valley Center for Rehabilitation and Nursing
IJJ
Manner of Death 0 Natural Cause Accident 1:1Homicide El Suicide Undetermined El Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
Cl Leonard Gelman MD
Address
10421 State Route 40,Granville Town,New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5756 11
ElBurial Date Cemetery,Crematory or Facility Name
01/29/2021 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
Date Point of
(/) u Transportation Shipment
p by Common
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
1— Remains are Shipped,If Other than Above
5 Address
CC
W
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/29/2021 Registrar of Vital Statistics Jenny Lind'_f9fartelkgkctramcaJ;Sgned)
(signature)
District Number 5756 Place Granville, 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 /, i Z2 f Place of Disposition ,3 e 0 4?cJ C 44-
�(
W (address)
W
CCCC (section) J (lot number)) (grave number)
Name of Sexton or Person in Cha a of Premise )?la ON v e
(please print)
W Signature / G{ Title DrE'�- S
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) l
7 b
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#