Musits, Elizabeth NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Elizabet Musits Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/29/2022 95 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
0 Manner of Death Undetermined Pending
�Natural Cause �Accident �Homicide �Suicide
() Circumstances Investigation
tU Medical Certifier Name Title
O Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 69
ElBurial Date Cemetery,Crematory or Facility Name
02/01/2022 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
tL Date Point of
Cl) Li Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
0 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
�• Address
1C
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/31/2022 Registrar of Vital Statistics MeganYoliin(Ekctronicalr Signed
(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 _
Z Date of Disposition 211 I It Place of Disposition
ILI e
�n (address) r ��—
W
lA CC (section)(section) 4 ( (lot number) (grave number)
1
Sexton or Person in Charge of Premises t��1pl� �^�
0 Name of
Z L /J/J /P`�ase print/
Signature Title
DOH-1555(o7/t8)p 1 of 2