Vermum, Yvonne Rose I_ii...\,.......,,,,,..,.F) It .....)Li i
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Perm t
Name .first Middle Last Sex
Yvonne R um Female
Date of Deat< Age If Veteran of U.S.Armed Forces,
09/17/2022 71 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Warrensburg Town Street Address 9 Hudson Street,Warrensburg Town,New York 12885
p Manner of Death ENatural CauseAccident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
O Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Warrensburg District Number Register Number
C' ,Town o r Vi lla$e 5660 15
Burial Date Cemetery,Crematory or Facility Name
09/19/2022' Pine View Crematory
Entombment Address
Cremation Oueensbury T ,New York
Donation
goRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
Pfi Date Point of
Transportation
a 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
H Remains are Shipped,If Other than Above
5 Address
it
w
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/19/2022 Registrar of Vital Statistics PlameraatLloya^(`E*ctro 'a3'SB
(signature)
District Number 5660 Place Town Of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition II ZI I Z� Place of Disposition '(•w
2 (address/
W �,,
CO
CC (section) !d h (lot number) ,,, Att, (grave number)
SName of Sexton or Person in C o Premises L. -
z (/ease print)
w Signature Title ltril '
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of ty �. Y delivered on ' , 20./
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# F"
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