Simon, Maude H. NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
t
Name First Middle Last Sex
Maude H.Simon Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/09/2021 83 Years War or Dates
1_ Place of Death Hospital,Institution or
W City,Town or Village Fort Edward Village Street Address 3 Prospect Street, Fort Edward Village, New York 12828
p Manner of Death ❑X Natural Cause ❑Accident 11:1Homicide ❑Suicide ❑Undetermined Pending
(W) Circumstances Investigation
0 Medical Certifier Name Title
Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 21
❑Burial Date Cemetery,Crematory or Facility Name
04/12/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
12 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
1—. Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/12/2021 Registrar of Vital Statistics /meeL.Waloney(fElectrowcaf Srgned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Li 113I ZI Place of Disposition .A. t,M�L 44th�
2 (address)
W
U)
CC (section) (lot n ber) (grave number)
Name of Sexton or Person in Charge of Premises Fi t 1TL n f
Z (please print)
lL Signature Title
i; ��C'"
DOH-1555(o7/18)p t of 2
ep
Public Health Law Sec. 4145(2b) 1 4714
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named onibutf,21 perrpit
Official Funeral Directors Reg.or License# ��