Basti, Donna Grace # fig
NEWYORK STATE DEPARTMENT OF HEALTH .11
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Donna Grace Basti Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/11/2020 74 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
WManner of Death Rcl Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
C Medical Certifier Name Title
Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 27
Burial Date Cemetery,Crematory or Facility Name
01/15/2020 Pine View Crematory
Entombment Address
RCremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
U) Hold Address
N
0-
IL Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Service 01444
Address
94 Saratoga Ave,S Glens Falls,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 01/14/2020 Registrar of Vital Statistics RP6eaA 7drewCAIAW(Elertronwaf Sgneq)
(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:
t—
Z Date of Disposition l 110 Place of Disposition ti r
(address/
W
Ir N (section) (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises t�, L 1�
z Z (p ase print)
W Signature Title ft "A
DO H-1555(07/18)p i of 2
Public Health Law Sec. 4145(2b) --
Receipt
Human remains of delivered on , 20_
i
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#