Backus, Grace g 1
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace Anna Backus Female
IN Date of Death Age If Veteran of U.S. Armed Forces,
fili February 22,2017 70 War or Dates
SiM
sz, Place of Death Hospital, Institution or
: City, Town or Village Glens Falls Street Address Glens Falls Hospital
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Manner of Death X Natural Cause ❑Accident E Homicide Suicide n Undetermined Pending
M Circumstances Investigation
':,` ' Medical Certifier Name Title
e " Farkana'Carnal Dr.
Address
iN 100 Park St.,Glens Falls,NY 12801
li Death Certificate Filed District Number Register Number
Nii City, Town or Village Glens Falls 5601 1 Z
❑Burial Date Cemetery or Crematory
February 24, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
0 and/or Address
E Hold
U
p Date Point of
N 1-1
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
k Remains are Shipped, If Other than Above
{;• Address
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Permission is hereby granted to dispose of the human remains described above as indicated.r -Date Issued '1 44 I ( T' Registrar of Vital Statistics LA) '''' .s •'�—A ql
}: (signatu )
District Number 5601 Place Glens Falls) hi }i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Z. /7 Place of Disposition /vie (Jj7 ,,,, j�,'ed�t4 ir"ye
g (address)
W
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O (section) /(lot number) (grave number)
pName of Sexton or rso n Charge of Pr ises j i. / i ✓i (94 kil e_che
Z (please print)
W
Signature i di Title Gam ,y oye--4 ,/-
(over)
DOH-1555(02/2004)