Baitina, Maia LF j
Town of Queensbury
Certification of Cremation
*MI Pine View Cemetery and Crematory
This certifies that the remains of: Maia Baitina
were cremated on February , 13 20 21 at the Pine View
(Month) (Day)
Crematorium, Queensbury, New York, and these are the cremated remains of said body.
Date of Death February 9 20 21 Age 95
(Month) (Day)
Funeral Home Singleton,Sullivan,Potter Funeral Home Registered No. 169
(Authorized Signature)
BAITINA
NAME Maia Baitina ' Age: 95
Lot Owner: Maia Baitina
Lot# Algonquin Sec. F #83 R 3 Grave# 1
Case: Urn
Died: 2/9/2021 Interrec4/7/2021
Funeral Home: Regan Denny Stafford
Cemetery: Pine View
,„ It I 0'
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Maia Baiting
Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/09/2021 95 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Argyle Town Street Address Washington Center For Rehabilitation And Healthcare
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
Leonard Gelman MD
Address
4573 State Route 40,Argyle Town,New York 12809
Death Certificate Filed District Number Register Number
City,Town or Village Argyle 5750 14
❑Burial Date Cemetery,Crematory or Facility Name
02/10/2021 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
y1 Transportation Shipment
G by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
�.. Remains are Shipped,If Other than Above
a Address
C
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/10/2021 Registrar of Vital Statistics SltelkyMckernongketronicall:yStgne4
(signature)
District Number 5750 Place Argyle, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/
WDate of Disposition ,g-/3-,2Di( Place of Disposition P; ,\)e f.t'ti�) Gv�t(46�_)
W
Q (section) (lot number) (grave number)
8 Name of Sexton or Person in Cha of Premises ��'/'ydr~c1 E. �,�'
Z (please print)
W Signaturery. � /�' Title
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 01 4 E .
Receipt
Human remains of • delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#