Perrotte, Joan Ann 45111 -ft 3 ito
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joan Ann Perrotte Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/18/2022 74 Years War or Dates
F- Place of Death Hospital,Institution or
W City,Town or Village Wilton Town Street Address 25 Corinth Mountain Road,Wilton Town,New York 12831
p Manner of Death ❑X Natural Cause Accident ❑Homicide OSuicide Undetermined 1-1
Pending
ILI
0 Circumstances Investigation
ILI Medical Certifier Name Title
Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 25
Burial Date Cemetery,Crematory or Facility Name
04/20/2022 Pine View Crematory
Entombment Address —
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
G. Date Point of
(/)ETransportation
Q by Common Shipment
Carrier Destination
El
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
I- Remains are Shipped,If Other than Above
2 Address
C
W.
G. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/20/2022 Registrar of Vital Statistics Susan Baldwin gCectronicaCCySigned)
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— L
z Date of Disposition 4I(ZI (jt Place of Disposition F 1��
W /a dress/
W
NCC (section) 'Cumber) �(grave number)
1.... Z.14i
0 Name of Sexton or Person in Charge of Premises H
a
.� — (please pr t/
W 12-
Signature Title ( ��}�
DOH-1555(07/18)p 1 of 2
qU
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#