Bannin, Julie NEW YORK STATE DEPARTMENT OF HEALTH ,�,. , _
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Julie M. Bannin Female
Date of Death Age If Veteran of U.S. Armed Forces,
s August 21, 2017 64 War or Dates
g Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 230-4 Robert Gardens North
aManner of Death in Natural Cause n Accident n Homicide n Suicide ❑Undetermined Pending
W Circumstances Investigation
Medical Certifier Name Title
Shannon Evellis,R,PA
Address
100 Broad Street,Glens Falls,NY
iii Death Certificate Filed District Number Rgg�er Number
>>� City, Town,or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
August 24, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
r; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
it:. Address
<] 53 Quaker Road, Queensbury,NY 12804
V' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
rj Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued (g. 6.1/4---( (( ')Registrar of Vital Statistics �_ C . ICE_
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uiDate of Disposition 8/ZS-1 R Place of Disposition e„t�s,-, (;o ff driv 1,
2 (address)
COILI
Ce
(section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises firs, ._. e•l
p� (pease print)
W ...4 (..
Signature (rt Title ref Alp I
(over)
DOH-1555(02/2004)