Brooks-Shirt, Jo Ann -17
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jo Ann Brooks-Short Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/09/2021 70 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
CI Manner of Death 0 Natural Cause ID Accident El Homicide Suicide Undetermined El Pending
W U Circumstances Investigation
W Medical Certifier Name Title
O Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 140
Burial Date Cemetery,Crematory or Facility Name
03/12/2021 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
Hold Address
0
a Date Point of
U) j Transportation Shipment
Q by Common
Carrier Destination
ElDisinterment 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
H. Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/12/2021 Registrar of Vital Statistics Xp6ert/7ndrew Curtis(ccYectronica/ 'Srgned)
(signature)
District Number 5601 Place Glens Falls, 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 3,./3. Place of Disposition �(� rJ e (J, �,�, C r�1 a j��( p
2 (address)
W
CC (section) (lot number) (grave number)
S Name of Sexton or Person in C arge of Prem. L) �l(v rJ ' 14 )DU et
(please print)
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 016$3 9
{
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#