Cornell, Andrea Marie R3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Andrea Marie Cornell Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/21/2022 30 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 42 Cherry Street,Glens Falls, New York 12801
p Manner of Death ❑Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman MD
Address
3767 Main Street,Warrensburg Town,New York 12885
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 59
ElBurial Date Cemetery,Crematory or Facility Name
01/25/2022 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
❑Removal Date Place Removed
and/or and/or Held
Hold Address
N
O
Q. 1-1 Date Point of
N ❑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
1— Remains are Shipped,If Other than Above
5 Address
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/25/2022 Registrar of Vital Statistics Megan Nolin(E1ectronicaflySigned)
(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:
Z L Fora_--
Date of Disposition A, 2Z Place of Disposition
2 (address)
W
CC
(sea/on) (lot number) (grave number)
SName of Sexton or Person in Cha of Premises
Z (p se pr/nt)
W Signature ( Title (.'P���
DOH-1555(07/18)p 1 of 2
0155 8 6
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#