Stephenson, Carol G. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Carol G.Stephenson I Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/10/2020 70 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 18 Ohio Avenue,Queensbury Town, New York 12804
p Manner of Death 91 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 98
❑Burial Date Cemetery,Crematory or Facility Name
05/12/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
ZO Removal Date Place Removed
and/or and/or Held
H Hold Address
N
O
G. Date Point of
Cl) ElTransportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
It
W
(L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/11/2020 Registrar of Vital Statistics CarofikexlJegarde 0.der(E1ectronw-1T Srgner9
(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:
W Date of Disposition S�Z��ZO Place of Disposition �i�evt C� G`e• �
(address)
2
W
N (section) at number) (grave number)
o
13 Name of Sexton or Perso ha of Premises GiN
(please print)
Z
W Signature Title
DOH-1555(07/18)p JA 2
Public Health Law Sec. 4145(2b) 70
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
,� Official Funeral Directors Reg.or License#