Sphan, Kathleen L it Oil
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathleen L.Spahn Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/20/2021 76 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 198 Bluebird Road,Moreau Town,New York 12803
p Manner of Death ❑X Natural Cause Accident ❑ Homicide ❑Suicide 0 Undetermined ❑Pending
Circumstances Investigation
WMedical Certifier Name Title
G Robert Love MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 62
❑Burial Date Cemetery,Crematory or Facility Name
12/21/2021 Pine View Crematory
EIEntombment Address
K❑Cremation Queensbury Town,New York
❑Donation
0 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
(/) ❑Transportation
by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
Date Cemetery Address
Reinterment
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
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/21/2021 Registrar of Vital Statistics Leeann lcca6e(EYectronicallySOned/
(signature)
District Number 4562 Place Moreau, 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 12123 f Z Place of Disposition � �L
1!1 I /address/
2
W
CC N (section) (lot number) c (grave number)
0 ^
Name of Sexton or Person in Charge of remises J�� �
Z (plea print)
W CRI
Signature Title
DOH-1555(o7/i8)p l of 2
l r, r -79
c.
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#