Monroe, Janice Pearl ]t 7 7(1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Janice Pearl Monroe Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/08/2022 85 Years War or Dates
,,_ Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens FaHs Hospital
p Manner of Death EI Natural Cause Accident El Homicide ESuicide ❑Undetermined ❑Pending
W
V Circumstances Investigation
GMedical Certifier Name Title
Asim Chaudry MD
Address
100 Park St,Glens Falls,New York 12801
DeaRth Certificate Filed city of Glens Falls District Number Register Number
City,Town or Village 5601 152
Burial Date Cemetery,Crematoryor Facility Name
03/10/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
goRemovalDate Place Removed
and/or and/or Held
pN Hold Address
0
O. Date Point of
Cl)❑Transportation
a 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
H Remains are Shipped,If Other than Above
rE Address
R
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2022 Registrar of Vital Statistics Megan.9lr)Iin(Ela ,vyAine4)
(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:``ff
lL._
Z Date of Disposition 3III 2Z Place of Disposition fyi
ess)
W
U)
CC (section) / t number) (grave number)
8 Name of Sexton or Person in Charge of P mises aril M.1 it
z
(please p�btl
W Signature S`^� Title ��� r4�t'�
DOH-1555(07/18)pi of 2
0 . 5 ''y 73
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#