Warner, Donna Darleen s
Public Health Law Sec. 4145(2b) i.r s 3
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
i. S"1► I V 1
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donna Darlene Warner Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/01/2021 58 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 63 Main Street,Queensbury Town,New York 12804
'p Manner of Death 0 Natural Cause Accident I=1 Homicide El Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 116
❑Burial Date Cemetery,Crematory or Facility Name
06/04/2021 Pine View Crematory
ElEntombment Address
ElCremation Queensbury Town,New York
ElDonation
• ElRemoval Date Place Removed
and/or and/or Held
- Hold Address
CO
0
�- 1-1 Date Point of
co Li Transportation
p 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
1.. Remains are Shipped,If Other than Above
$ Address
Cr
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/04/2021 Registrar of Vital Statistics CarnlineYllgard Barger((lectronicaf Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
W Date of Disposition �pr� Place of Disposition !i)e (Ja ,rr,�,� E'l,e, .y t
2 (address)
W
N (section) (lot number) (grave number)
Name of Sexton or Person in Charge of remises T� Ynia.�
Z (please print)
W Signature Title 0 ,
;# f �
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 01487a
Receipt
Human remains of delivered on , 20
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#