Martyniak, Henrietta A NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle ;; Last Sex
Henrietta A.Martyniak Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/01/2021 78 Years War or Dates
�., Place of Death Hospital,Institution or
WCity,Town or Village Bolton Town Street Address 707 Valley Woods Road,Bolton Town,New York 12814
Manner of Death Natural Cause 0 Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
ILI 0 Medical Certifier Name Title
Eileen Spinelli NP
Address
Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Bolton Landing 5650 15
0 Burial Date Cemetery,Crematory or Facility Name
11/08/2021 Pine View Crematory
El Entombment Address
EICremation Queensbury Town,New York
0 Donation
Removal Date Place Removed
-IL- and/or and/or Held
Hold Address
0
d Date Point of
(/) ❑Transportation
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
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 11/08/2021 Registrar of Vital Statistics Jodi Petteyr(ilectronicallj Signed
(s/gnature)
District Number 5650 Place Bolton Landing, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H r�
Z Date of Disposition (t I/ I Zi Place of Disposition
W
2 (address)
W
CC (section) A (lot number/ (grave number)
aName of Sexton or Person in Charge of miser , 1 r q f;t
Z (please print)
W Signature ` ( TitleIII EA
g
DOH-1555(07/18)p 1 of 2
015314
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial pelrmit
Official Funeral Directors Reg. or License#