Baldwin, Virginia Chapman oy
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Virginia Chapman Baldwin Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/01/2021 97 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
in Manner of Death 0 Natural Cause Accident I=1 Homicide El Suicide El Undetermined El Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
0 Kelly Maley PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 321
❑Burial Date Cemetery,Crematory or Facility Name
08/03/2021 Pine View Crematory
11 Entombment Address
Cremation Queensbury Town,New York
ElDonation
Z Removal Date Place Removed
and/or and/or Held
U Hold Address
)
0
n. Date Point of
f/) Li Transportation Shipment
G 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
Remains are Shipped,If Other than Above
g Address
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/03/2021 Registrar of Vital Statistics 90 Afrer*'Cu>tzsglectronicat Signea9
(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:
Z
Date of Disposition g/S 114 Place of Disposition 474..1 Ot'
(address
2
W
NCC (section) (lot number) (grave number)
0
Name of Sexton or Person in Charge of Premises t` tM�N�T
(plea print)
W • Title `"W
Signature
DOH-1555(07/18)p i of 2
a
Public Health Law Sec. 4145(2b)
1 Receipt
1
Human remains of delivered on __-3 , 20
//
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# .