May, Grace Lorraine , ti Iv
•
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Grace Lorraine May Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/13/2021 86 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 25 McCormack Drive,Queensbury Town,New York 12845
p Manner of Death 0 Natural Cause ❑Accident ❑Homicide Ei Suicide ❑Undetermined Pending
UCircumstances Investigation
W Medical Certifier Name Title
0 Jennifer Hayes MD
Address
200 Smith Drive,Corinth Town,New York 12822
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 120
Burial Date Cemetery,Crematory or Facility Name
06/15/2021 Pine View Crematory
❑Entombment Address
gCremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
f/) L j Transportation Shipment
p by Common
Carrier Destination
El
Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
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
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/15/2021 Registrar of Vital Statistics Carotinexkiegard Barbir(Ekctronical6,S9nee9
(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:
I—
W (,Date of Disposition i n VI Place of Disposition RftpL df►.!�
2 (address)
W
CC CC (section) (lot number)c (grave number)
AA it
O Name of Sexton or Person in Charge of ises (" �'' �`
/p ase print/
z C/ `e .
W Signature Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) . 4 8 r
Receipt
Human remains of delivered on / : , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
9