Coulard, Jeanette Frances (
} ��� Burial - Transit Permit
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Name First Middle Last Sex
Jeanette Frances Coulard Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/25/2023 87 Years War or Dates
1— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
ui Medical Certifier Name Title
0 Asim Chaudry 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 54
Burial Date Cemetery,Crematory or Facility Name
. 01/31/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
!- Hold Address
N
0
0. Date Point of
U) Transportation Shipment
5 by Common
Carrier Destination
Disinterment El
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
2 Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2023 Registrar of Vital Statistics Megan No(in(ECectronicaClySigned)
(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:
I- -----,
/
Z Date of Disposition Z I 1 I-i3 Place of Disposition y�
�
(addre
ILI
2 ss)
W
N CC (section) (lot number/ (grave number)
S of Sexton or Person in Ctarge of Pre 's L' S -
NameZ /pleas print/
W Signature Title r^ P2
DOH-1555(o7/A8)pi of 2
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CI 6 6 5 Uw
,
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#