Shippee, Genevieve Louise it 722
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Genevieve Louise Shippee Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/06/2022 77 Years War or Dates
f„ Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
O Manner of Death El Natural Cause ❑Accident 0Hornicide ❑Suicide Undetermined ❑Pending
Ur
Circumstances Investigation
{j j Medical Certifier Name Title
C Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
DeaHth Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 50
Burial Date Cemetery,Crematory or Facility Name
03/09/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
nDonation
Z❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
B. Date Point of
(I)DTransportation Shipment
a by Common
Carrier Destination
Disinterment Date Cemetery Address
ElResnterment 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
F.. Remains are Shipped,If Other than Above
a Address
CC
Ur
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/08/2022 Registrar of Vital Statistics Carolrfexldgard(Barter(''h tronkany Signe&
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 3/I)'Z'Z Place of Dispositions /4/.1—..._
2 (address)
W
N (section) 4flot number) (grave number)
fn
g Name of Sexton or Person in Charge of Prem. s (r-_ ,matt
z
(plea e print/ //
III Signature ..., Title t rie. nft rot
DOH-1555(07/18)p 1 of 2
`:s ! F87
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home nam4on burial permit
Official Funeral Directors Reg.or License#