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Clements, Lois I NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Lois G. Clements 93 :•.g Date of Death Age If Veteran of U.S. Armed Forces, •' 10/21/2017 93 War or Dates n/a �. Place of Death Hospital, Institution or - City, Town or Village Queensbury Street Address 118 Chestnut Ridge Rd. a• Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending ,•' Circumstances Investigation . Medical Certifier Name Title w,. • Robert Love, MD Address 'R Irongate Center, Glens Falls, NY i... Death Certificate Filed District Number Register Number ; =1� City, Town or Village Queensbury 5657 ❑Burial Date Cemetery or Crematory ❑Entombment Address ❑Cremation Donation Date Place Removed ZZ n Removal 10/21/2017 and/or Held Harvard Medical College and/or Address t"` Hold Boston, MA N O Date Point of NTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address pi Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01442 • Address 53 Quaker Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom •; Remains are Shipped, If Other than Above Address r Permission is hereby granted to dispose of the human emains described ab v as indicated. re n Date Issued 10(A_t J 1—Registrar of Vital Statistics �C^'�-1-�--{ • _ t;:% (signature) District Number 1'�� ") Place 0 �r.\ v, ( -L I certify that the remains of the decedent identified above were disfposedd Qof in acc� •-t e with thispermit`on: '� �\ \��lC, t Q f=2 Ps W` Date of Disposition 1t k 1I Place of DispositionA ,; W (address) Cl) Q° section, _ �t (lot number) (grave number) p Name of Sexton r Pe o in Charge of Premises 1 Wr (p/e print), Signature Title��C '� l u r-t'C-'C13Y' WfD (over) DOH-1555(02/2004) , Tosteson Medical Education Center Harvard Medical School 1:1 ©=; 9 260 Longwood Avenue Anatomical Gift Program s,.; Boston, MA 02115 617-432-1735 AGP@hms.harvard.edu November 7,2017 Queensbury Town Hall 742 Bay Road Queensbury,NY 12804 Dear Sir or Madam, Please find enclosed, for your records, the burial transit endorsement for Ms.Lois Gubitz Clements, who died on 10/21/2017. Sincerely, Tracey y Manager,Anatomical Gift Program enclosure HMS,Anatomical Gift Program, ID# 4735