Sprepski, Anne Marie # 51C
NEW YORK STATE DEPARTMENT OF HEALTH (i .! !i Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Anne Marie Sprepski Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/25/2022-• 68 Years War or Dates
ZPlace of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death l Natural Cause Accident El Homicide Suicide EUndetermined ElPending
Circumstances Investigation
Q Medical Certifier Name Title
Robert Love MD
Address
3 Irongate Center,Glen&Falls,New York 12801
Death Certificate Filed ci' Glens Falls District Number Register Number
City,Town or Village --.. 5601 334
Burial Date Cemetery,Crematory or Facility Name
06/28/2022 Pine View Crematory
Entombment Address
EjCremation Queensbury Town,New York
DDonation
Z❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
CO❑Transportation
b by Common Shipment
Carrier Destination
ODisinterment 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
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/28/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(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:
I— 'l
W Date of Disposition b/l' 177 Place of Disposition n1U� Or
2 (address)
Ili
N (section) (lot number) (grave number)
S°` LSol
Name of Sexton or Person in Charge o ises r
z it_
print) •
W Signature7 Title ��FiMq j�►q
DOH-1555(o7/t8)p 1 of 2
` ic0c2
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# {"