Barody, Mary Jo te r . 110
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Jo Barody Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/10/2021 63 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 17 Donna Avenue, Moreau Town,New York 12803
UJ
o Manner of Death El Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined 0 Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
0 Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 24
❑Burial Date Cemetery,Crematory or Facility Name
05/12/2021 Pine View Crematory
0 Entombment Address
gCremation Queensbury,New York
ElDonation
Date Place Removed
Removal and/or Held
F and/or
N
Hold Address
0
Date Point of
N ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,New York 12804
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
OC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/11/2021 Registrar of Vital Statistics Geeanngfcca6egieectronicallySigned)
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f
Date of Disposition .cI lZ("LI Place of Disposition (address L o--
LIJ
N (section) (!ot number/ number)
Ir
0 Name of Sexton or Person in Charge of Prem. s 5.,,AdtzT (grave
O (Plea print)
W SignatureZ Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01. 4776
Receipt
Human remains of ` delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#