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Fernbach, JoEllen L @ it NEW YORKSTATE DEPARTMENT OF HEALTH 83 8 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex JoEllen Fernbach Female Date of Death Age If Veteran of U.S.Armed Forces, 10/13/2023 75 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 6 Fielding Street,Glens Falls,New York 12801 pManner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation ui Medical Certifier Name Title 0 Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 484 Burial Date Cemetery,Crematory or Facility Name 10/18/2023 Pine View Crematory Entombment _ Address ©Cremation Queensbury Town,New York DDonation ZO❑Removal Date Place Removed and/or and/or Held F— Hold Address N 0 O. Date Point of Cl) Transportation p by Common Shipment Carrier Destination EDisinterment 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 i— Remains are Shipped,If Other than Above a Address C W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/18/2023 Registrar of Vital Statistics Megan No(in(ECectronicalTySigned) (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 /0 Ili 43 Place of Disposition f' / 0 (fr c n 2 (address) W N CC (section) (lot number/ (grave number) SName of Sexton or Person in Charge of Premises i A rest,ad. .„, m,.4it Z /ease print) W Signature Title Cleo flArba ..„a DOH-1555(07/18)p 1 of 2 1 3R7 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#