Duckfield, Terri LeAnne Weaver I 7o7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Terri LeAnne Weaver Duckfield Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/25/2022 57 Years War or Dates
i_ Place of Death Hospital,Institution or
Z-City,Town or Village Glens Falls Street Address 7 Division Street Apt#3,Glens Falls,New York 12801
pManner of Death El Natural Cause EAccident 0 Homicide ESuicide ❑Undetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 143
Burial Date Cemetery,Crematory or Facility Name
03/07/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ZO0Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
U)❑Transportation Shipment
S by Common
Carrier Destination
!DisintermentDate 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
S Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/07/2022 Registrar of Vital Statistics Megan Yolk gketronicalYYS*Ines
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F— ZV...-
WDate of Disposition 311 I ZZ Place of Disposition
2 (address)
W
CC CC (section) j (lot number) (grave number)
/(I
8 Name of Sexton or Person in Charge of Pr ses
z
(pleas print/
fW Signature Title 644-41►4111Z
DOH 1555(o7/18)p t of 2
A 1...
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named op burial permit
Official Funeral Directors Reg.or License#