DiRoma, Fay s
T — NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Fay Constance DiRoma Female
f Date of Death Age If Veteran of U.S. Armed Forces,
. June 24,2015 79 War or Dates n/a
-, Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death L2ikm7 Natural Cause ❑Accident ❑Homicide ❑Suicide C Undetermined 1-1 Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Sponzo,MD
Address
• Glens Falls,NY
r Death Certificate Filed District Number RegVirber
City, Town or Village Glens Falls, NY 5601
®Burial Date Cemetery or Crematory
❑Entombment Address
29, 2015 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
o and/or Address
Hold
N
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
MA Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
r 53 Quaker Road, Queensbury,NY 12804
• Name of Funeral Firm Making Disposition or to Whom
1 7_' Remains are Shipped, If Other than Above
Address
j Permission is hereby granted to dispose of the human remains de /ri e�ab ve icated.
�rf
ice,'':. Date Issued �0�2��2O/.T Registrar of Vital Statistics ,����
1,tf (signature)
• District Number S(Pp/ Place p� ., /74/ , /f/
f�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 6/30/201 5Place of Disposition Pine View Cemetery, Oueensbury, NY
W (address)
U) 695, Wah—Ta—Wah 26 4
(section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signature L L J ..,k_c Title Cemetery Superintendent
(over)
DOH-1555(02/2004)