Atiyeh, Harriet Jane NEWYORKSTATEDEPARTMENTOFHEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Harriet Jane Atiyeh Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/07/2021 86 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 60 Mohican Street,Glens Falls,New York 12801
• Manner of Death ❑X Natural Cause ❑Accident 1=1Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
MI Medical Certifier Name Title
Christopher Hoy MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 238
O Burial Date Cemetery,Crematory or Facility Name
06/09/2021 Pine View Crematory
❑Entombment Address
O Cremation Queensbury Town,New York
ElDonation
Z ri Removal Date Place Removed
and/or and/or Held
N Hold Address
N
0
CI. ❑ Date Point of
t/) 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
F— Remains are Shipped,If Other than Above
Address
CL
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/08/2021 Registrar of Vital Statistics Xp6ertf7ndreu'Curtis(EYectronicaf Signed)
(signature)
District Number 5601 Place Glens Falls, 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 (PM 11,' Place of Disposition ,,�,L
,2 (address)
W
CCCC (section) (lot number) (grave number)
GName of Sexton or Person in Charge of P emises
Z (plea print)
W Signature Title (kN'w11)4
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 1 4 8 5
Receipt
Human remains of delivered on , 20<<
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#