Kingsley, Shirley June IOW
NEWYORKSTATEDEPARTMENTOFHEALTH - i ��
BurialTransit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley June Kingsley Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/27/2022 74 Years War or Dates
H Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 4 Sparrow Way Apt.A,Queensbury Town,New York 12804
p Manner of Death ❑X Natural Cause 0Accident I:Homicide 0 Suicide ❑Undetermined 0 Pending
W C.) Circumstances Investigation
W Medical Certifier Name Title
G Andrew Coates MD
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 44
❑Burial Date Cemetery,Crematory or Facility Name
03/01/2022 Pine View Crematory
❑Entombment Address
K❑Cremation Queensbury Town,New York
ElDonation
Z ❑Removal Date Place Removed
- and/or and/or Held
~- Hold Address
N
0
Date Point of
N Li Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
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
H Remains are Shipped,If Other than Above
2 Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/01/2022 Registrar of Vital Statistics Carolnexkligarde Barb-er(Ekctronica(Signed)
(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:
l— �
Z Date of Disposition 312 (2'Z Place of Disposition `l t^..tt-Vo-'— r- r .__L
W (address)
W
NCr (section) /lot number) (grave number)
GName of Sexton or Person in Charge of Premises /pleas print/
IIz
Zji
�� (IVA4HIv
W Signature Title
DOH-1555(o7/18)p 1 of 2
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#