Crispino, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vita/Records Section Burial - Transit Permit
F{{ Name First Middle Last Sex
f s
Anne C. Crispin Female
• Date of Death Age If Veteran of U.S. Armed Forces,
August 4,2012 67 War or Dates
▪ Place of Death Hospital, Institution or
City, Town or Village Queensbury,NY Street Address 23 Lynnfield Drive
Manner of Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical ertifier Name Title
is `fr' c \ Fir\ rnI)
0. Address , I
P Death Certificate Filed j District Number i R ist Number
City, Town or Village Queensbury,NY 5657
®Burial Date Cemetery or Crematory
❑Entombment August 7,2012 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
• and/or Address
1' Hold
N .
0 Date Point of
N ❑Transportation Shipment
p 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
y
53 Quaker Road, Queensbury,NY 12804
tr' Name of Funeral Firm Making Disposition or to Whom
Y''. Remains are Shipped, If Other than Above
Address
- Permission is hereby granted to dispose of the human remains describeabove as indicated.
1
dd cc �
• Date Issued0,(� l (a, Registrar of Vital Statistics ,
(signature
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 8/7/1 2 Place of Disposition Pine View Cemetery
N (address)
N Erie 7 E 2
rL (section) (lot number) (grave number)
pName of Sexton or Person i rge of Premises Michael Genier
Z (please print)
W
Signature Title Superintendent
(over)
DOH-1555(02/2004)