Mcllveen, Carol Ann Iz
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Per it
Bureau of Vital Records
Name First Middle Last Sex
Carol Ann Mcllveen Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/02/2024 89 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
O Manner of Death Natural Cause Accident Homicide OSuicide Undetermined ri Pending
ILI Circumstances Investigation
W Medical Certifier Name Title
Mikram Jafri MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 23
Burial Date Cemetery,Crematory or Facility Name
02/06/2024 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0ā¯‘Removal Date Place Removed
and/or and/or Held
f- Hold Address
0
O. Date Point of
d)ā¯‘Transportation
es by Common Shipment
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
F. Remains are Shipped,If Other than Above
a Address
W
Q. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2024 Registrar of Vital Statistics Caroline x(degarde Barber(E(ectronicalty 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:
IF-
W Date of Disposition 21 7 121 Place of Disposition .fiiJr if;lc,.) (Pfinti ?A21 LiN.,
2 (address)
W
EC EC (section) (lot number) (grave number)
/
gName of Sexton or Person in Charge of Premises ! (.34 riot/ ne 1
Z /
W Signature E Title `
DOH-1555(07/18)p 1 of 2
.. '0
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#