Gibney, Heather Kathleen 3S-0
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Heather Kathleen Gibney Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/09/2021 53 Years War or Dates Coast Guard
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 13 Arlington Street,Glens Falls,New York 12801
Manner of Death Undetermined Pending
G Natural Cause Accident Homicide Suicide X
IW Circumstances Investigation
W Medical Certifier Name Title
0 Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 178
❑Burial Date Cemetery,Crematory or Facility Name
04/14/2021 Pine View Crematory
EjEntombment Address
X❑Cremation Queensbury Town,New York
EjDonation
o ElRemoval Date Place Removed
and/or and/or Held
F- Hold Address
to
0
Date Point of
U) Li Transportation
p 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
2 Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/14/2021 Registrar of Vital Statistics V'p&ertAndrew Curtis((lectronicaf Signed)
(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:
ZW Date of Disposition Lb/5 Zf Place of Disposition —.67A.A ., v«r
(address)
W
CC N (section) lot number) (grave number)
Name of Sexton or Person in Charge of Pre .ses L
Z / (please ri S�
nt)L
W Signature l Title 4 ''4 �
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
1