Rhodes, Lois , , A Kil
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
*a.' Name First Middle Last Sex
4r_, Lois DeLong Rhodes Female
Date of Death Age If Veteran of U.S.Armed Forces,
It
VA 10/29/2018 92 Years War or Dates
Place of Death Hospital, Institution or
r City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ?❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
Circumstances Investigation
Medical Certifier Name Title
Stephen Perazzelli MD
Address
14:,X 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
.;;;- City, Town or Village Glens Falls 5601 510
'El Burial Date Cemetery or Crematory
A. 10/31/2018 Pine View Crematory. ❑Entombment Address
aZ
®Cremation Queensbury, New York
Date Place Removed
a ❑Removal and/or Held
and/or Address
Z Hold
e Date Point of
;k ❑Transportation Shipment
by Common Destination
*, Carrier
❑Disinterment
Date Cemetery Address
0 Date Cemetery Address
❑Renterment
�,r
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 10/31/2018 Registrar of Vital Statistics qg6ertACurtis(ECectronicalTySigned)
(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:
„ Date of Disposition Jilt Ill Place of Disposition ,c.,d6- fr tor,
(address)
it
in
te (section) h (lot number) (grave number)
pName of Sexton or Person in Charge of Premises tA(+� S tnnt l'
l (p/ se print)
Signature Title IiLEfild4TO/t-
(over)
DOH-1555(02/2004)