Harding, Theresa Rose t- 1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Theresa Rose Harding Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2023 56 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
`p Manner of Death El Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Gamal Khalifa MD
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 50
p
Burial Date Cemetery,Crematory or Facility Name
01/27/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
ElDonation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
O. Date Point of
Cl) Transportation
b by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
OReinterment 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
F Remains are Shipped,If Other than Above
2 Address
CC
11' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2023 Registrar of Vital Statistics Megan Wain(ECectronicalrySigned)
(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:
Z
W Date of Disposition /3j 73 Place of Disposition
(address)
W
N (section) (!w number) (grave number)
S°� ��� � �
Name of Sexton or Person in Charge of Premises
Z %pease print/
W Signature Title C +)fNq
DOH-1555(07/18)p 1 of 2
i f
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on buria -
Official Funeral Directors Reg.or License •