Ralph, Stephanie Lynn _UV
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Stephanie Lynn Ralph Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/16/2019 54 Years War or Dates
t.. Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address 366 Luzeme Road,Queensbury Town, New York 12804
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
Alexis Mondella NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury --75657 169
Burial Date Cemetery,Crematory or Facility Name
11/19/2019 Pine View Crematory
Entombment Address
0 Cremation Queensbury,New York
Donation
Z Removal Date Place Removed
and/or and/or Held
N Hold Address
O
a Date Point of
U) ❑Transportation Shipment
jS by Common
Carrier Destination
El Disinterment
Date Cemetery Address
JE]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 or to Whom
Remains are Shipped,If Other than Above
Address
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/19/2019 Registrar of Vital Statistics Carolnexfd--.4arde Bader(EYectronicalySipwd)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II)1o111 Place of Disposition n.Va l �•
Uj
U (address)
W
(sedan) (tot n ber/ /grave number)
Name of Sexton or Person in Charge of Premises �`
(ple a print)
W Signature Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) �"`!" 0 1 3 0 q 1_
Receipt
Human remains of delivered on , 20_
Pine ViewJCemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#