Worthing, Maureen Bridget I-LF) it 101I
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Maureen Bridget Worthing Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/15/2022 75 Years War or Dates
i_ Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 19 Whippoorwill Road,Queensbury Town,New York 12804
p Manner of Death EI Natural Cause Accident 0 Homicide OSuicide Undetermined ❑Pending
IIJ
O Circumstances Investigation
IIJ Medical Certifier Name Title
a Darci Gaiotti-Grubbs MD
Address
If 100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 191
Burial Date Cemetery,Crematory or Facility Name
12/20/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
p- and/or and/or Held
N Hold Address
0
O. Date Point of
CO❑Transportation
p 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
-. Remains are Shipped,If Other than Above
5 Address
Ill
lii
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/20/2022 Registrar of Vital Statistics CarolinexIgarde Barher(EkctronicalySigned)
(signature)
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:
I— `—__,(�
W Date of Disposition $Z hi I IL_ Place of Disposition /,�Ll— C 1,4i-0
(address)
W
LC N (section) d (lot numb (grave number)
gName of Sexton or Person in Charge of P ises / . L-
z se print)
W Signature Title �(Zl�/Y11 F}
,./7---
DOH-1555(07/18)p 1 of 2
i
Public Health Law Sec. 4145(2b) s_
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#