Hopper, Doris Jean SC6
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Doris Jean Hopper Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/07/2021 89 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 17 Honeysuckle Lane,Queensbury Town,New York 12845
W
Manner of Death 0 Natural Cause ❑Accident ❑Homicide El Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
CI Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 140
Burial Date Cemetery,Crematory or Facility Name
07/08/2021 Pine View Crematory
❑Entombment Address
lCremation Queensbury,New York
ElDonation
g Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
d Date Point of
N 0 Transportation
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
I— Remains are Shipped,If Other than Above
5 Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/08/2021 Registrar of Vital Statistics Caroline xnfegarde Barber(EkctronicarySigned)
(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:
H
Z Date of Disposition 7 .-,, p j( Place of Disposition'tl e J;e« 4 g'r_.1
2 (address) ---+
W
N (section) (lot nu ber) (grave number)
q
0 Name of Sexton or Person in Char e of Premis 1 y/ n/ - l✓/�
(please print)
W Signature r- Title rytS' vS---
DOH-1555(07/18)p 1 of 2
I Public Health Law Sec. 4145(2b) 01.4 9 2 6
Receipt
Human remains of delivered on ' a , 20 ,_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
S