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Crevoiserat, Florence Gloria -7(Fi5r, NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Florence Gloria Crevoiserat Female Date of Death Age If Veteran of U.S.Armed Forces, 11/17/2019 93 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address 100 Park Street,Glens Falls,New York 12801 Manner of Death ©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending W Circumstances Investigation V Medical Certifier Name Title Madison Zuis NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 494 ❑Burial Date Cemetery,Crematory or Facility Name El Entombment 11/19/2019 Pine View Crematory Address RCremation Queensbury Town,New York ❑Donation ❑Removal Date Place Removed 111— and/or and/or Held N Hold Address M ❑Transportation Date Point of a by Common Shipment Carrier Destination ❑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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition orto Whom } Remains are Shipped,If Other than Above Address 1C W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/19/2019 Registrar of Vital Statistics 4?p6ertAndrew Curtis(ECectronicalTy Signed) !signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition J �°�() Place of Disposition wW,..J (address/ W (section) (lot nu erl (grave number) Name of Sexton or Person in Charge of remises z leas intl W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013090 Receipt Human remains of delivered on , 20— Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# - ,