De Lauri, Teresa Anne 5 )
NEW YORK STATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Teresa Anne De Lauri Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/06/2021 88 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 16 Cortland Street,Glens Falls,New York 12801
p Manner of Death 11 Natural Cause Accident El Homicide El Suicide ❑Undetermined 11 Pending
W V Circumstances Investigation
W Medical Certifier Name Title
O Thomas Coppens MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 278
Burial Date Cemetery,Crematory or Facility Name
07/09/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
0 ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
G. Date Point of
f/) L j Transportation Shipment
Q by Common
Carrier Destination
❑Disinterment
Date Cemetery Address
Date Cemetery Address
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
Remains are Shipped,If Other than Above
2 Address
C
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/09/2021 Registrar of Vital Statistics Ro6ert/?nrlrewCurtis(Electronica(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 7-1P-4'$2/ Place of Disposition 'Pi Ate ); ) C,ev1q -
(address)
W
(section) (lot number) (grave number)
O '7A`PikutiJ E. '1doae
O Name of Sexton or Person in Charg of Premis
Z (please print)
W Signature Title O ei„-vid�
DOH-1555(07/18)p i of 2 1
•A,�
Public Health Law Sec. 4145(2b) 01 3 8
Receipt
Human remains of delivered on , 20—
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#