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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane Ann Baker Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/01/2022 79 Years War or Dates
k Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
11.1
O Manner of Death [ ]Natural Cause []Accident 0 Homicide Suicide Undetermined Pending
W U Circumstances Investigation
W Medical Certifier Name Title
O Christopher Smith MD
Address
100 Park St,Glens Falls,New York 12801
DeaRth Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 452
Burial Date Cemetery,Crematory or Facility Name
09/02/2022 Pine View Crematory
Entombment Address
IIICremation Queensbury Town,New York
Donation
ZRemoval Date Place Removed
and/or and/or Held
F_-' Hold Address
CO
0
0. Date Point of
(AD Transportation Shipment
p by Common
Carrier Destination
[]Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped,If Other than Above
5 Address
CC
WI
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/02/2022 Registrar of Vital Statistics Megan Noun(ECectronica1TySigned)
(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:
k-
Z Date of Disposition cf I 7,1 ZZ, Place of Disposition4`Ii.V.-- /*------
11J (address)
W
O (section) /f'list number) _. , (grave number)
tt
0 Name of Sexton or Person in Charge o Premises
Z (pie a print)
W rivi
Signature Title `rybn
DOH-1555(o7/t8)p 1 of 2
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#