Decker, Diana NEW YORK STATE DEPARTMENT OF HEALTH Section
Vital S eco Burial - Transit Permit
r�is
rr,:, Name First Middle Last Sex
aDiana _ C. Decker Female
T. Date of Death Age If Veteran of U.S. Armed Forces,
;,p,;;; February 28, 2014 _ 54 War or Dates
"_ Place of Death Hospital, Institution or
1. City, Town or Village Queensbury Street Address 8 Heinrick Circle
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
.r Eric Pillemer MD
Address
;:: Glens Falls Hospital, Park St,Glens Falls,NY 12801
1 Death Certificate Filed District Number ' Register Number
c.x. City, Town or Village Queensbury 5657 c-)
0 Burial Date Cemetery or Crematory
March 5, 2014 _J Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z Removal i and/or Held
and/or Address
t. Hold
Cl) --
0 Date Point of
O.
Transportation Shipment
a 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
r° Address
53 Quaker Road,Queensbury,NY 12804
{f. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address 1r
i.,4 Permission is hereby granted to dispose of the human e ains describ above as indicated.
r:., )) Q.
:a Date Issued 31�:.Ol Registrar of Vital Statistic �-�l A .-
r: (signature)
'j5 District Number 5657 Place Queensbury
e
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W 3/5/1 4 Pine View Cemetery
Date of Disposition Place of Disposition
W (address)
Mohican 84H 3
tY (section) (lot number) (grave number)
8 Name of Se C
ton or Person in Charge of Premises Connie L. Goedert
(please print)
UJ
Signature b•. -,2Crc.E.v( Title Superintendent
(over)
DOH-1555(02/2004)