Cartier, Mary Lou 11414111461\
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Lou Cartier Female
Date of Death Age If Veteran of U.S..Ocifiltd Forces,
11/30/2021 83 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 66 Cedar Court,Queensbury Town,New York 12804
W
Manner of Death ❑X Natural Cause El Accident Homicide El Suicide �Undetermined 0 Pending
W Circumstances Investigation
W Medical Certifier Name Title
O George Siniapkin MD
Address
604 Palmer Avenue,Corinth Town,New York 12822
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 231
riBurial Date Cemetery,Crematory or Facility Name
12/01/2021 Pine View Crematory
Entombment Address
ElCremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
f- Hold Address
0
0. Date Point of
to 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
Remains are Shipped,If Other than Above
M Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/01/2021 Registrar of Vital Statistics Caroline 9fi/ gardeBar6er(Electromcall:ySWned)
(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:
Z Date of Disposition 12I1 IZ+ Place of Disposition
(address)
W
2 (section) ((lot numb (grave number)
0 Name of Sexton or Person in Charge of Pr ises 4‘,., '°^'t
Z (please print)
W L._/ `� II Fir►te$(U�
Signature Title
DOH-1555(07/18)p 1 of 2
}_r 01. 53 8
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#