Gigon, Rose Anna t. •- -,, fi
3
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rose Anna Gigon Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/05/2022 89 Years War or Dates
1— Place of Death Hospital,Institution or
Z City,Town or Village East Greenbush Town Street Address Evergreen Commons
p Manner of Death ❑X Natural Cause IllAccident Homicide Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
G Elizabeth Jones NP
Address
1070 Luther Rd,East Greenbush Town,New York 12061
Death Certificate Filed Town Of East Greenbush District Number Register Number
City,Town or Village 4152 47
Burial Date Cemetery,Crematory or Facility Name
03/09/2022 Pine View Crematory
Entombment Address
EiCremation Queensbury Town,New York
Donation
g E Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
d) 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
N Address
CC
W
D. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/09/2022 Registrar of Vital Statistics Eden cPang6urn(E(ectronicalTySigned)
(signature)
District Number 4152 Place Town Of East Greenbush
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ 44r
WDate of Disposition 3�(1�i!Z Place of Disposition ��
2 (address
uJ
CC CC (section/ F /t(ll tnumber) sii6ti
(grave number)
GName of Sexton or Person in Charge of Premise
Z (pl e print) / 7vit
W Signature 6� Title G 1 vt�
DOH-1555(07/18)p t of 2
4 -�
C . `-1,7
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#