Loading...
Urband, Alice NEW YbRK SATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Alice Urband Female Date of Death Age If Veteran of U.S. Armed Forces, March 1, 2013 102 War or Dates Place of Death Hospital, Institution or ZCity, Town or Village Glens Falls, Street Address The Pines At Glens Falls ▪ Manner of Death X Natural Cause n Accident ( Homicide n Suicide —Undetermined ]Pending W —Circumstances Investigation W Medical Certifier Name Title C Suzanne Rayeski,MD Address 170 Warren Street,Glens Falls,NY 12801 Death Certificate Filed District Number Register.Number City, Town or Village Glens Falls 5601 9? ©Burial Date Cemetery or Crematory March 5, 2013 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road, Queensbury, ,NY 12804 Date Place Removed ZZ U Removal and/or Held and/or Address Hold Cl) O Date Point of yn Transportation Shipment a by Common Destination Carrier ( Disinterment Date Cemetery Address Reinterment ' Date CemeteryAddress 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 Remains are Shipped, If Other than Above _ 2 Address LLB W a Permission is hereby granted to dispose of the human remains des ribed abo ,e as d'cated. Date Issued 3 Or20/3 Registrar of Vital Statistics ,,�2 �ti' (signature) District Number 5601 Place Glens Falls /v/ /o2OJ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 3/5/1 3 Place of Disposition Pine View Cemetery 1111 (address) New KenPsaw 4 & 21 B 1 CC (section) (lot number) (grave number) 00 Name of Sexton or Person in Charge of Premises .,..9/c✓ Nem,2&/" Z (please print) Signature Title (over) DOH-1555(02/2004)