Padasak, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Louise Padasak Female
Date of Death ' Age If Veteran of U.S. Armed Forces,
8/4/2018 79 War or Dates
.. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 28 Marigold Drive
p Manner of Death I X I Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
O Ageel A Gilloni,MD
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village s to � c O'7
❑Burial Date Cemetery or Crematory
❑Entombment August 8,2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
OZ n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
ri Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
to
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ,--'1 - 1' Registrar of Vital Statistics --T-a,41-k- -h.ke Q&e.,k_--
(signature)
District Number j to S 7 Place Q 0 c e n S bv/
I certify that the remains of the decedent identified above were posed of in accordance with this permit on:
I-
wDate of Disposition 9113/Ig Place of Disposition &Li rmit,...,/
W (address)
Cl)
p0 (section) (lot nu er) (grave number)
Name of Sexton or Person in Charge of Premises 11r,.h4' ,5A•
Z W Signature it
/(� Title (please print ""
(over)
DOH-1555(02/2004)