Di Croce, Jean , ► 3 / ?
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Le Name First Middle Last Sex
r,;;, Jean Claire DiCroce Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 17, 2017 88 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Manner of Death
Street Address Glens Falls Hospital
:s X Natural Cause n Accident —_Homicide n Suicide pi Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Susanne Rayeski
N Address
r> ; 100 Park Street,
,Glens Falls,NY 12801
. p,. Death Certificate Filed District Number Register Number
:.::•A. City, Town or Village Glens Falls 5601 c7
❑Burial Date Cemetery or Crematory
April 19, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
E Hold
0 Date Point of
O.
❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
il`' Permit Issued to Registration Number
ni Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Mii Address
`` 53 Quaker Road, Queensbury,NY 12804
mii
<r::: Name of Funeral Firm Making Disposition or to Whom
it Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued _t(t ci ill Registrar of Vital Statistics W`-•"0"9-�.)(signatur )
District Number 5601 Place Glens Fallgiiiis Nf`j
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Yl79//7 Place of Disposition I i r ve—U (- ,J CletiyLe„ ,v
W (address)
co
ix
(section) t number) (grave number)
p Name of Sexton or ers in Charge of Premises J tom- i )c L'v 1 et, e
Z ( (please print)
W
Signature Title 6.yC,- 0r
(over)
DOH-1555(02/2004)