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Firth, Carol Ann LF # Y3 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Carol Ann Firth Female Date of Death Age If Veteran of U.S.Armed Forces, 10/17/2023 80 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Moreau Town Street Address 6 Amber Lane,Moreau Town,New York 12828 aManner of Death ❑X Natural Cause Accident Homicide Suicide nUndetermined Pending W I 1Circumstances Investigation W Medical Certifier Name Title G Darci Gaiotti-Grubbs MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 57 Burial Date Cemetery,Crematory or Facility Name 10/19/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation OZ Removal Date Place Removed and/or and/or Held H Hold Address N 0 a Date Point of (A Transportation Shipment p by Common Carrier Destination Disinterment 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 1— 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 10/19/2023 Registrar of Vital Statistics Brenda 7futter(ECectronicaltySigned) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition JpIto 1 Z.3 Place of Disposition rsrv16r,N„c,,J , 6R ,/yt�T � dcRrv+,_, 2 (address) W NCC (section) (lot num-- (grave number) SName of Sexton or Person in Charge f Premises r. 4s11 z p/ease print) W Signature Title f DOH-1555(07/18)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#