Martin, Lois Louise NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lois Louise Martin Female
Date of Death Age If Veteran of U.S.Armed Forces,
07/08/2021 72 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 336 Ridge Road, Queensbury Town, New York 12804
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Robert Love MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 143
ElBurial Date Cemetery,Crematory or Facility Name
07/13/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
EIDonation
O• ElRemoval Date Place Removed
and/or and/or Held
F- Hold Address
0
CL Date Point of
co Li 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
1— Remains are Shipped,If Other than Above
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/13/2021 Registrar of Vital Statistics CaroItnelareganf Barb-er(EkaroncallyStgne4
(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:
WDate of Disposition "7/i i r' 74 Place of Disposition 491 J.J
2 (address)
W
O (section) �� (lot number) (grave number)
� t�
O Name of Sexton or Person in Charge of remises ^ l
Z �� (p/ese print)Title CPt"11�4
Signature
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014 9,3 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#