Callonnec, Jean Mary 4 hyy
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jean Mary Callonnec Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/05/2021 99 Years War or Dates •, ;-'
1_ Place of Death Hospital,Institution or
W I__I City,Town or Village Glens Falls Street Address The Pines At Cis Falls Center For Nursing&Rehabilitation
• Manner of Death Natural Cause 0 Accident Homicide 0 Suicide Undetermined El Pending
LU Circumstances Investigation
WMedical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5001 326
Burial Date Cemetery,Crematory or Facility Name
08/06/2021 Pine View Cremator
❑Entombment Address
0 Cremation Queensbury Town,New York
ElDonation
gEl Removal Date Place Removed
and/or and/or Held _
N Hold Address
0
d Date Point of
to 11 Transportation
p 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
F— Remains are Shipped,If Other than Above
Address
ICJ
LL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/06/2021 Registrar of Vital Statistics RP6ertf?ndrewCurtzr(E/ctronca(y5 ner)
(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:
F—
W Date of Disposition g 7 14 Place of Disposition ��... C iDlt�
2 (address)
W
CC N
(section) I (lot number) c ,I� (grave number)
GName of Sexton or Person in Charge of Pre s �, ►, .� ` '"^^'�
Z (p 4ase print) ..��
W Signature Title 04
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#