Frederick, Jeanette T. $ ySd
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeanette T.Frederick Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/25/2021 92 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 8 Lynnfield Drive,Queensbury Town, New York 12804
p Manner of Death ❑X Natural Cause Accident Homicide ❑Suicide Undetermined ❑Pending
W
C.) Circumstances Investigation
W Medical Certifier Name Title
CI Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 115
ElBurial Date Cemetery,Crematory or Facility Name
05/28/2021 Pine View Crematory
Entombment Address
gCremation Queensbury Town,New York
EIDonation
❑Removal Date Place Removed
and/or and/or Held
i- Hold Address
i!)
0
a. Date Point of
f/) ❑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
H Remains are Shipped,If Other than Above
"S Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/28/2021 Registrar of Vital Statistics Carngnexdiegarde Bader(Electronical'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:
Z Date of Disposition le I I -.4 Place of Disposition 7. u
W
2 (address)
W
CC N (section) tot number) (grave number)
Name of Sexton or Person in Charge of Premis s !� �-- a�^'���
2 pleaseint)
UJ
Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 14 81-
Receipt
1 Human remains of delivered on , 20 'i „
1 Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# • I
1