Gibson, Judith Ann T. it. ell 0
NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transit Pe�it
Bureau of Vital Records
Name First Middle Last Sex
Judith Ann Gibson Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/17/2022 78 Years War or Dates
1,,. Place of Death Hospital.Institution or
Z City,Town or Village Queensbury Town Street Address 2438 Montcalm Apartments,Queensbury Town,New York 12804
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p Manner of Death l Natural Cause ❑Accident 0 Homicide OSuicide ❑Undetermined ❑Pending
W Circumstances Investigation
WMedical Certifier Name Title
0 Patricia Stevenson PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
a�e
0 5657 100
Burial Date Cemetery,Crematory or Facility Name
Addre2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
(Donation
�+'�- Removal Date Place Removed
and/or and/or Held
NHold Address
0
O. Date Point of
CO❑Transportation Shipment
b by Common
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
1— Remains are Shipped,If Other than Above
j Address
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O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/20/2022 Registrar of Vital Statistics Camlttu.7!rar4aeiar*er('Pmm.Y 4)
(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:
t-
WDate of Disposition 6 I ll I ZZ Place of Disposition 'f'ni Ur..� �—
2 (address)
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NCC (sea/on) X (jot number) (grave number)
SName of Sexton or Person in Charge of Pr .ses h' �-' '"``'t
Z (please print) �
W /
Signature // Title G W
Sig
DOH 1555(07/18)p 1 of 2
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fl1 6f202
Public Health Law Sec. 4145(2b)
Receipt
Human remains of :'' delivered on , 20
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#