Heck, Carol NEW YORK STATE DEPARTMENT OF HEALTH (1......
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Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Carol Heck Sex
Female
Date of Death
Age If Veteran of U.S.Armed Forces,
06/28/2022 78 Years War or Dates
Place of Death Hospital,Institution or
Z
City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Q Manner of Death ['Natural Cause Accident Homicide Suicide Undetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 342
Burial Date Cemetery,Crematory or Facility Name
06/30/2022 Pine View Crematory
Entombment Address
['Cremation Queensbury Town,New York
❑Donation
0 El Removal Date Place Removed
F and/or and/or Held
N Hold Address
0
O. Date Point of
CD❑Transportation
O by Common Shipment
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
f.- Remains are Shipped,If Other than Above
N Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/30/2022 Registrar of Vital Statistics Megan Wolin(E(ectronica((ySigned)
(signature)
A 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 7/--2O2Z Place of Disposition A ctect) r't e./v.iI
,j
,us (address)
lf
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Pr ises �R t/rfiG� (JOcv to
✓ iG"/' (please print)
Signature Title ce-eX
DOH-1555(01(1s1 p iof 2
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of ' delivered on e ' , 20
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Pin 'View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#