Payne, Marion Louise St 71
..
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
t
Name First Middle Last Sex
Marion Louise Payne Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/21/2022 92 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 51 Evergreen Lane Apt.104,Queensbury Town,New York 12804
• Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
U
W Medical Certifier Name Title
CI Paul Filion MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 20
❑Burial Date Cemetery,Crematory or Facility Name
01/21/2022 Pine View Crematory
❑Entombment Address
K❑Cremation Queensbury Town,New York
Donation
Z• Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
co ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
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
-. Remains are Shipped,If Other than Above
a Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/21/2022 Registrar of Vital Statistics Carolnexnfegar1t Barber(ElectronicallySigned)
(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:
W
Date of Disposition /7z_ z z z Place of Disposition ., J p
2 (address)
W
CC (section) a (lot number)
(grave number)
G Name of Sexton or Person in Charge of Premisees Rt�Y �/✓�� �E�E
(please print)
W Signature '� A�Y ((� Title "V e- s-z i-
DOH-1555(07/18)p 1 of 2
C y i
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#