De Loria, Nancy 1(0'
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy D. DeLoria Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 3, 2017 78 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ❑X Natural Cause Accident ❑Homicide Suicide n Undetermined ❑Pending
W: Circumstances Investigation
W; Medical Certifier Name Title
Sean Bain MD
Address
100 Park Street
Death Certificate Filed District Number Register N ber
City, Town or Village Glens Falls 5601 n.
❑Burial Date Cemetery or Crematory
February 6, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ElRemoval and/or Held
and/or Address
H Hold
V)
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
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
l Remains are Shipped, If Other than Above
2 Address
rt
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2 I ! / I Registrar of Vital Statistics �°C 'i'"
(signature)
District Number [ bo 1 Place 5601 ( QjvNS `\.S Ny
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Z(i IQ Place of Disposition I)Iilit,r 441*4-dcw�
2 (address)
W
CO
O (section) / (lot number)(-` (grave number)
pName of Sexton or Person in Charge of Pr mises tArigifr— ,t4iitZ ( ase print)
W
Signature Title (� mlfi(�(�
(over)
DOH-1555(02/2004)