Durham, Jacqueline Ann hF
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jacqueline Ann Durham 4/y Female
Date of Death Age If Veteran of'ti.S.Ara Forces,
01/16/2023 75 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
p Manner of Death El Natural Cause Accident 0 Homicide ESuicide OUndetermined ElPending
IU Circumstances Investigation
WMedical Certifier Name Title
C Julian Marynczak PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 29
RBurial Date Cemetery,Crematory or Facility Name
01/18/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
Z
O❑Removal Date Place Removed
and/or and/or Held
H Hold Address
U)
0
n. Date Point of
U)ETransportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
f-Pe'rmit 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
2 Address
CC
in
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/18/2023 Registrar of Vital Statistics Megan Noliitg ctronicalry Signed)
(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:
W
Date of Disposition i/Zo I Z3 Place of Disposition -r,,,,,k( /.7t"'�—.
2 (address)
uJ
O (section) 71,;(lot number)l ,st ti (grave number)
G Name of Sexton or Person in Charge of Premises ��(`
d (plFase print)
Z wi19Yt-
W Signature Title
DOH-1555(o7/18)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#