Dobert, Nancy Barbara („7
NEW YORK STATE DEPARTMENT OF HEALTH - . Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nancy Barbara Dobert Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/18/2022 84 Years War or Dates
ZZ Place of Death Hospital,Institution or
City,Town or Village Saratoga Springs Street Address 400 Church Street, Saratoga Springs, New York 12866
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p Manner of Death Eki Natural Cause El Accident ❑Homicide I:ISuicide ❑Undetermined 0 Pending
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U Circumstances Investigation
0 Medical Certifier Name Title
Mirabelle Beck NP
Address
394-402 Church Street,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Saratoga Springs 4501 51
ElBurial Date Cemetery,Crematory or Facility Name
01/21/2022 Pine View Crematory
El Entombment Address
gCremation Queensbury Town,New York
ElDonation
Z• Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
a Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
El 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
1— Remains are Shipped,If Other than Above
2 Address
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0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/20/2022 Registrar of Vital Statistics I3illon Moran gYectronica*Signee9
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H 1,
Z Date of Disposition '(7l I R Place of Disposition i��Y` 4i4 r„
2 (address)
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CC CC (section) (lot number) (grave number)
A g Name of Sexton or Person in Charge of Premises t(O ., cott
mAL(
z (piece print)
W Signature 6 Title 6 �'M�}
DOH-1555(07/18)p 1 of 2
0
Public Health Law Sec. 4145(2b) �
Receipt
I
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#