Bombard, Sandra A. • tO
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Sandra A Bombard Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/10/2021 79 Years War or Dates
F— Place of Death Hospital,Institution or
W City,Town or Village Albany Street Address Albany Medical Center Hospital
• Manner of Death E Natural Cause ID Accident 1=1 Homicide El Suicide Undetermined Pending
WJ Circumstances Investigation
Medical Certifier Name Title
0 Olga Martin PA
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed cDistrict Number Register Number
City,Town or Village '�';. Albany 0101 1256
11 Burial Date= Cemetery,Crematory or Facility Name
05/14/2021 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
Donation
O Removal Date Place Removed
and/or and/or Held
- Hold Address
O
CL 1-1 Date Point of
t/) ❑Transportation
O by Common Shipment
Carrier Destination
El
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
I— Remains are Shipped,If Other than Above
Address
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/13/2021 Registrar of Vital Statistics Daniell SCiaupie(EkctranicalfySigned)
(signature)
District Number 0101 Place Albany, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
R �L Z Date of Disposition Sifl �2( Place of Disposition ti►�,
2 (address)
W
N
(section) A number) (grave number)
O• Name of Sexton or Person in Charge of Premis
(please pr t)
W Signature Title C4')`4117
DOH-1555(07/18)p t of 2
1 Public Health Law Sec. 4145(2b) 1.ti 7 8 7
Receipt
i
Human remains of delivered on , 20.E
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#