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Schermerhorn, Phyllis Marie 111C-1:f) A- S5 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Phyllis Marie Schermerhorn Female Date of Death Age If Veteran of US.Armed Fortes, 01/14/2024 86 Years War or Dates i_ Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital UJ 0 Manner of Death ❑X Natural Cause Accident Homicide OSuicide Undetermined riPending 11.1 Circumstances Investigation W Medical Certifier Name Title C 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 31 RBurial Date Cemetery,Crematory or Facility Name 01/16/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 6 Removal Date Place Removed and/or and/or Held H Hold Address N 0 EL Date Point of U)ETransportation p by Common Shipment Carrier Destination EIDisinterment 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 O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/16/2024 Registrar of Vital Statistics sleganWoln(ECectronica1 ySigned) (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 + I /W I Place of Disposition �Ji"iinYti..) G01,"1 2 (address) W NIt (section) A.,(lot number) C (grave number) Name of Sexton or Person in Charge of Pre `-- -j/v„(blase print) W Signature Title l Iv omm 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# ; !