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Grishkot, Joan Barbara \-"C NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Joan Barbara Grishkot Female Date of Death Age If Veteran of U.S.Armed Forces, 07/08/2021 79 Years War or Dates i_ Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address 202 Ridge Street,Glens Falls,New York 12801 Q Manner of Death Ej Natural Cause El Accident El Homicide ❑Suicide D Undetermined El Pending W V Circumstances Investigation W Medical Certifier Name Title CI 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 281 ©Burial Date Cemetery,Crematory or Facility Name 07/14/2021 Pine View Cemetery Entombment Address ❑Cremation Queensbury Town,New York 11 Donation dRemoval Date Place Removed - and/or and/or Held i- Hold Address N 0 O. Date Point of in ❑Transportation Shipment p by Common 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 i.- Remains are Shipped,If Other than Above 2 Address IX W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/11/2021 Registrar of Vital Statistics Rp6ert/7nrlrew Curtis-gkctronica/ySWnea9 (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: Date of Disposition 7/1 4/2 0 2 1Place of Disposition 21 Quaker Road, Queensbury NY 12804 (address) W Erie 81 B 2 NCC (sedan) (lot number) (grave number) a Connie Goedert Name of Sexton erson in Charge o emises 0 (p/ease print) W Signature font e, Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012862 Receipt --- , Human remains of --,, , ,, •....,k kit V\0 i delivered on - , / i , 20 (-3 i ... i I i 4,../A4/ 7 e II I z / / Af • e View Cemetery , ' Official Representing the'funeral home named on burial permit Funeral Directors Reg.or License# li 1 1 "i /_-_, Grishkot (1-4!) NAME Joan Barbara Grishkot Age: 79 Lot Owner: Joan Grishkot Lot# Erie 81 B Grave# 2 Case: Concrete Died: 7/8/2 0 21 Interred:7/1 4/2 0 21 Funeral Home: Baker FH Cemetery: Pine View