Scrime, Angeline NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last- Sex
Angeline Rose Scrime Female
Date of Death Age If Veteran of U.S.Armed Forces,
0612412018 82 Years War or Dates
Place of Death Hospital, institution or
City,Town or Village Granve.village Street Address Indian River Rehabilitation And Nursing Center
Manner of Death 0 Natural Cause Accident 0 Homicide El Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Kandora MD I _
Address
17 Madison St,Granville Village,New York 12832 ! _
Death Certificate Filed District Number Register Number
City,Town or Village Granville Vllage 5725 29
❑Burial Date Cemetery or Crematory
06/26/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York ( _
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier •
0 Disinterment
Date Cemetery Address
Reinterrnent 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
Permission is hereby granted to dispose of the human remains described above as indicated-
Date Issued 06/2512018 Registrar of Vital Statistics 41(idanf406rrts fictrouicu Sypd
(signature)
District Number 5725 Place Granville image, New Yolk
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 4 in it T Place of Disposition 0.44-0
(addiesa)
_ I
(fin) n number) c (grave number)
Name of Sexton or Person in Charge of Premises `,a :^'`tf
Signature ifii Title
( irlE1TOR�
(aver)
DOH-1555(02/2004)