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Burt, Thea May
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thea Mae Burt Female Date of Death Age If Veteran of U.S.Armed Forces, 12/24/2021 93 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing W Manner of Death Undetermined Pending W Natural Cause Accident Homicide Suicide Circumstances Investigation W Medical Certifier Name Title O Wendy Steinhacker PA Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 250 ©Burial Date Cemetery,Crematory or Facility Name 12/30/2021 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York ▪Donation 0 Removal Date Place Removed and/or and/or Held i- Hold Address 0 EL Date Point of (i) 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 2 Address EC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/28/2021 Registrar of Vital Statistics Carolinexkfegard Bader(ElectronicallySOned) (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: H Z Date of Disposition l�-3U. (2/ Place of Disposition 7/ ) ki rS� (Lt(-cy�5 1,jCi,try fly / W (address) w �-�7I-.� N cc (section) (lot number) (grave number) CName of Sexton or Person in Charge of Premises a�n�1�C �� C�Q Z (please print) W Signature .�V� Title )�, c-�n11c�T1� DOH-1555(o7/i8)p i of 2 Public Health Law Sec. 4145(2b) 012889 Receipt Human remains of delivered on f , 20 I 1 Pine View Cemetery Representing the funeral home named on burial permit Official `J Funeral Directors Reg.or License# BURT J,Lr . NAME Thea Mae Burt s Age: 93 Lot Owner: Clarence & Thea Burt Lot# Huron 21 D Grave# 2 Case: Concrete Died: 1 2 .2 4 .21 Interred: 1 2.3 0.21 Funeral Home:Baker FH Cemetery: Pine View