Gang, Maxine Sydney NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Maxine Sydney Gang Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/30/2021 89 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 21 Windy Ridge Road,Glens Falls,New York 12801
W
pManner of Death a Natural Cause D Accident ❑Homicide ❑Suicide ElUndetermined El Pending
V Circumstances Investigation
W Medical Certifier Name Title
0 Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 473
Burial Date Cemetery,Crematory or Facility Name
11/01/2021 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
ElDonation
g ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d. Date Point of
N Li Transportation
p by Common Shipment
Carrier Destination
0 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
l— Remains are Shipped,If Other than Above
5 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2021 Registrar of Vital Statistics To6ertf7ndrew Curtis.(EkctronicallySWnei
(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 as/3 I -I Place of Disposition e474,41 `f'ka'r�
2 (address)
W
N
(section) (lot number) W (grave number)
4 _
gName of Sexton or Person in Charge of Premises fi � •+
0 (p ase print)
�y//
W Signature Title OW
DOH-1555(07/18)p 1 of 2
< < F jai(Q)
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#