Green, Lola .y
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.:: Name First Middle Last I Sex
Lola A. Green 1 Female
Date of Death 1 Age ! If Veteran of U.S. Armed Forces,
February 5, 2012 I_ 70 I War or Dates
H Place of Death I Hospital, Institution or
Z City, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
LU
Manner of Death I }Natural Cause I I Accident Homicide Suicide Undetermined l Pending
W: Circumstances Investigation
W Medical Certifier Name Title
Address
Death Certificate Filed District Number Register Number
City, Town or Village
❑X Burial Date Cemetery or Crematory
May 25,2012 Southside Cemetery
El Entombment Address
❑Cremation Gansevoort Road South Glens Falls, NY 12803
Date Place Removed
O I I Removal and/or Held
and/or Address
E Hold
Cl)
O Date Point of
N 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
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
Address
g
0.' Permission is hereby ranted to dispose of the human rer ains described above as indicated.
Date Issued 1 Co &31aegistrar of Vital Statistics
(signature)
District Numbe oc ) Place -b Z C >r Q S1.,
I certify that the remains of the decedent identified above were disposed of in accor nce ith this permit on:
W Date of Disposition Place of Disposition
2 (address)
W
Cl)
re (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
Z (please print)
W Title
Signature
(over)
DOH-1555(02/2004)