Ricciardelli, Donna Lee * I 27
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donna Lee Ricciardelli Female
Date of Death Age If Veteran of US.Armed Forces,
02/01/2023 ," 81 Years War or Dates
f.. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing
ILI
p Manner of Death Z Natural Cause ❑Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Elizabeth Bessette NP
. Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 15
Burial Date Cemetery,Crematory or Facility Name
02/06/2023 Pine View Crematory
_Entombment Address
IICremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
E Hold Address
CO
0
a. Date Point of
CO❑Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
ElReinterment 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
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/02/2023 Registrar of Vital Statistics Caroline x(degarc(e Barber(ECectronica((y Signed)
(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:
W Date of Disposition Z h 73 Place of Disposition , r
2 (address)
W
CO
CC (section) 4 . (lot numi (grave number)
ti
g Name of Sexton or Person in Charge of P i es IL_
z (please print)
W Signature Title (Ir'‘'n 1
DOH-1555(07/i8)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# , `