Costello, Jane Rebecca ,.. LF 4 3tit
NEW YORK STATE DEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane Rebecca Costello Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/22/2022 57 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 122 Sherman Avenue,Glens Falls,New York 12801
a Manner of Death El Natural Cause Accident 0 Homicide OSuicide ElUndetermined ❑Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or Village
g 5601 223
Burial Date Cemetery,Crematory or Facility Name
04/25/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDon atio n
❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d. Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
pReinterment
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 Otherthan Above
5 Address
Q
LU
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/2512022 Registrar of Vital Statistics Afigan9tro!sn(Elsctmn Srgnes9
(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: /�
Date of Disposition ii/25iZZ Place of Disposition 1' 6 ors`_
W 1
2 (address)
W
UN
Ir a (section) (lw number/ (grew numbed
Name of Sexton or Person in Cha a of Premises 01 fil u 54nt`1
Z (plea print/
Ill Signature Title � 1,61��'`
DOH 1555(07/18)p 1 of 2
01 F
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#