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Domenech, Mary Gomez 4 gS� NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Mary Gomez Domenech Female Date of Death Age If Veteran of U.S.Armed Forces, 10/08/2021 66 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 35 Evergreen Lane,Queensbury Town,New York 12804 ' Manner of Death ©Natural Cause ❑Accident ❑Homicide ElSuicide ❑Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Charles Yun MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 206 Burial Date Cemetery,Crematory or Facility Name 10/12/2021 Pine View Crematory ❑Entombment Address lCremation Queensbury,New York ElDonation 0 ElRemoval Date Place Removed and/or and/or Held ~ Hold Address N 0 a. 1-1 Date Point of to ❑Transportation CI Common Shipment Carrier Destination El Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as Indicated. Date Issued 10/12/2021 Registrar of Vital Statistics Caroline 1uilfegarde Barber(E(ectronicalty Signed) (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: ZtL Date of Disposition 101 IT Ili Place of Disposition �it��i... Jtd ry _ (address) W CC N (sedan) (lot number/ (grave number) SName of Sexton or Person in Charge of Pre ises 46;1 �6t Z (please print/ W Signature ti Title CMK�� DOH-1555(o7/i8)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#