Mazzeo, Marilyn Annette s • -y 531
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marilyn Annette Mazzeo Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/02/2021 85 Years War or Dates
i.., Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause 0 Accident Homicide El Suicide Undetermined Pending
WLi
U Circumstances Investigation
MI Medical Certifier Name Title
0
Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 484
0 Burial Date Cemetery,Crematory or Facility Name
11/04/2021 Pine View Crematory
0 Entombment Address
ElCremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
H and/or and/or Held
N Hold Address
0
d Date Point of
(!) Li 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
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/04/2021 Registrar of Vital Statistics Ro6ert Andrew Cultic(E/ctronica(5gned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of y'.ent identified above were disposed of in accordance with this permit on:
W14 Date of Disposition 's Place of Disposition ,KCl r--
2 (address)
Ill
U)
SCC (section) dt.;.k.N,L._(l t nuum ber) c (grave number)
Name of Sexton or Person in Charge of Premises 11
z (ple se print)
W Si natures /'
g Title G�V�'$
DOH-1555(07/18)p 1 of 2
' 0152 9 "
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 '
r
Pine View Cemetery Representing the funeral home named Ca-burial permit
Official Funeral Directors Reg.or License#