Dosiek, Helen t Io (
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Helen Dosiek Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/15/2021 93 Years War or Dates
�,. Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W
p Manner of Death El Natural Cause I=1 Accident Homicide El Suicide Undetermined Pending
Ui Circumstances Investigation
W Medical Certifier Name ��`Title
CI Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 604
❑Burial Date Cemetery,Crematory or Facility Name
12/16/2021 Pine View Crematory
ElEntombment Address
g Cremation Queensbury Town,New York
Donation
ZZ ri Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Date Point of
U) 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
N Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/16/2021 Registrar of Vital Statistics ?Zo6ertf7ndrew Curtis(E'lectronicallySignea9
(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:
H I
Z Date of Disposition 121 i-11 Z4 Place of Disposition . M IL X'„4 Jr;u�
2 (address)
W
CC N
(section) / (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premise ` r`` ri ti
Z (p1 ase print)
W • Title `�^M&1
Signature
DOH-1555(07/18)p 1 of 2
215 •5
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#