Bright, Pauline NEW YORK STATE DEPARTMENT OF HEALTH 377
Vital Records Section Burial - Transit Permit
Name First Last Sex
Pauline E.Middle Bright Female
Date of Death 0 7/1 0/2 01 7 Age 8 4 If Veteran of U.S. Armed Forces,
War or Dates
i- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
O Manner of Death ®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
VCircumstances Investigation
W Medical Certifier Name Title
O Gamal Khalifa
Address 100 Park St Glens Falls, NY
Death Certificate Filed Glens Falls I District Number ` I Register Number
City, Town or Village n 3 ._c
❑Burial Date 07/10/2017 Cemetery or Crematory nine View Crematory
❑Entombment Address
21 QtakeY d Queensbury, NY
[Cremation
Date Place Removed
Z El❑ and/or He2ld Removal -N.
aHoldor Address
nd/
O Date Point of
❑Transportation Shipment _
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Edward L Kelly Funeral Home 00519
Number
Name of Funeral Home
Address Schroan Lake, NY 12870
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
i:r. F
W
fl` Permission is hereby granted to dispose of the human remains described� above as indicated.
Date Issued 7 ( (0 ( (7 Registrar of Vital Statistics c&($ LA.)
(signature) `
District Number 56() i Place /�S FCC S � j
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
1,1 Date of Disposition 11 ii 1(1 Place of Disposition e,.10✓ Crw,.wfio:,._. t
W (address)
0
IX (section) lot number) ^ (grave number)
GName of Sexton or Person in Charge of Premises firs ,.. tAsNi11`
z (pleas print)
Lli
Signature a %tO` Title rREf t( -
(over)
DOH-1555 (02/2004)