Eastily, Lillian NEW YORK'STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lillian Eastily Female
Date of Death Age If Veteran of U.S. Armed Forces,
pA ri19, 2013 93 War or Dates
.:7 Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause U Accident + I Homicide n Suicide n Undetermined piPending
Circumstances Investigation
Medical Certifier Name Title
Mathew Varughese,MD
0 Address
100 Park Street,Glens Falls,NY 12801
s
.� Death Certificate Filed District Number Register Number
x, Cit TownGlens Falls 5601 ��
y, or Village
0 Burial Date Cemetery or Crematory
El Entombment April 12, 2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z Removal and/or Held
9. and/or Address
1:' Hold
N
0 Date Point of
Nr Transportation Shipment
a by Common Destination
Carrier
Ti Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53Quaker Road, Queensbury, NY 12804
�; _
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
APermission is hereby granted to dispose of the human remains desc i.e. ab/ - a 'cated.
{' Date Issued (� �® Z0/3 Registrar of Vital Statistics /r' �`
(signature)
District Number 5601 Place Glens Falls / 2 y 7,72k7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 4/1 2/1 3 Place of Disposition Pine View Cemetery
W (address)
c Seneca 22H 1
(section) (lot number) (grave number)
p Name of Sext n or Person in Charge of Premises Connie Goedert
Z (please print)
W Signature:` o Title Superintendent
1
(over)
DOH-1555(02/2004)