O'Brien, Mary Ellen , .@, 111
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Mary Ellen O'Brien Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/24/2022 68 Years War or Dates
Place of Death Hos 1,Institution or
ZCity,Town or Village QueensburyTown Street ress 126 Adirondack St,Queensbury Town,New York 12804
gMan ner of Death El NaturalDAccident OHornicide OSuicide ❑Undetermined Pending
V- Circumstances Investigation
W Medical Certifier Name Title
0 Mode Warren NP
Address
9 Carey Road,Queensbury Town,New York 12804 Nhil I
Death Certificate Filed Town Of Queensbury f)istrid Number Register Number
Cit ,Town or VillageE 5667 138
Burial Date Cemetery,Crematory or Facility Name
091
271
2022 Pine View CrematoryEntombment Address
EICremation Queensbury Town,New York
Donation
gpRemoval Date Place Removed
and/or and/or Held
F Hold Address
N
d Date Point of
(p❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
Re interment
Permit Issued to Registration Number
Name of Funeral Home MaYnard 0 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
Q
la
a.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/26/2On Registrar of Vital Statistics CamGrm.?li14gastfi Alder(Efoctmnr Siittoc0
/signsturel
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: /�L.
W Date of Disposition Place of Disposition I►neY`�- `�✓1w✓""�
(address)
W
CO
CC (section) /7 (lot number) (gra he number)
g Name of Sexton or Person in Charge 7mises A n tl
(plea print/
z (, mr1IN
W Signature Title
DOH-1555(07/18)p t 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# 1`` >