Park, Pauline4bjI
NEW YORKSTATE DEPARTMENT OF HEALTH
Bureau of Vital Records
Burial - Transit Permit
Name First Middle Last
Sex
Pauline L. Park
Female
Date of Death
Age
If Veteran of U.S. Armed Forces,
10/12/2019
99 Years
War or Dates
Place of Death
Hospital, Institution or
WCity,
Town or Village Johnsburg Town
Street Address Elderwood at North Creek
p
Mannerof Death Natural Cause Accident Homicide Suicide Undetermined Pending
W
Circumstances Investigation
U
W
Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd, Johnsburg Town, New York 12853
Death Certificate Filed
District Number
Register Number
City, Town or Village North Creek
5655
42
Burial
Date
Cemetery, Crematory or Facility Name
10/15/2019
Pine View Crematory
ElEntombment
Address
Nil Cremation
Queensbury, New York
EIDonation
Removal
Date
Place Removed
z
and/or Held
~
and/or
Hold Address
N
O
d
Date Point c f
N
Q
❑ Transportation Shipment
by Common
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 or to Whom
I—
Remains are Shipped, If Otherthan Above
Address
Q
W
lL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/15/2019 Registrar of Vital Statistics Kat%t%en C. Lorafe (ElectronicalTy Sa rned)
(signature)
District Number 5655 PlaCe North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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n _
Z
Date of Disposition 10 1S I i I Place of Disposition
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2
(address)
W
U)
(section) (tot number (grave number)
GName
of Sexton or Person in Charge of Premises 1 � t
(ease print/
int)
Z
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Signature Title
DOH-1555 (07/18) p i of 2
Public Health Law Sec. 4145(2b)
ul?599
Receipt
Human remains of
Pine View Cemetery
Official
delivered on / / r' , 20
Representing the funeral home named on burial permit
Funeral Directors Reg. or License #i - I -- -;