Hansen, Paula Jo NEW YORK STATE DEPARTMENT OF HEALTH r Q7..t.- Burial - Transit Per it
Bureau of Vital Records
Name First Middle Last Sex
Paula Jo Hansen Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/27/2022 76 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death 0Natural Cause ❑Accident Homicide Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
U�,} Medical Certifier Name Title
O Christopher Smith MD
Address
I 100 Park St,Glens Falls,New York 12801
Dea9th Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 291
Burial Date Cemetery,Crematory or Facility Name View/2022 Pine Crematorium
Entombment Address
Cremation Oueensbtry Town,New York
Donation
Z Removal Date Place Removed
oiDand/or and/or Held
i Hold Address
f)
0
Date Point of
(/)[Transportation Shipment
p, by Common
Carrier Destination
Date Cemetery Address
❑Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcderrnott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/31/2022 Registrar of Vital Statistics „Wigan�Yoltn(I1i 'trfr.411yStne4
(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:
W Date of Disposition 4 I III V. Place of Disposition f,,.rtL
(address)
W
N (section) (lot number) �{ (grave number)
Qf'`I
GName of Sexton or Person in Charge of Premises ^ r`
Z (ptase print/
W A,/ Title fi 1
Signature
DOH 1555(07/18)p 1 of 2
y .nab
Public Health Law Sec. 4145(2b)
Receipt
• r
Human remains of t` 'l �; *`, ! ,A.: ; `delivered on , 20
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Pine View Cemetery Representing the funeral home named gn,buual.perit
Official Funeral Directors Reg.or License# % -' `