Meyer, Kathleen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kathleen Theresa Meyer Female
Date of Death Age If Veteran of U.S. Armed Forces,
8/19/2018 91 War or Dates
E- Place of Death I Hospital, Institution or
Z City, Town or Village Lake George Street Address 1 Front Street
W Manner of Death [i Natural Cause I I Accident n Homicide 7 Suicide pi Undetermined p Pending
Circumstances Investigation
W Medical Certifier Name Title
O William Tedesco,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Lake George,NY
Burial Date Cemetery or Crematory
❑Entombment August 22,2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
Hold
N
O Date Point of
O.
0 Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
Il Remains are Shipped, If Other than Above
2 Address
d Permission is hereby granted to dispose of the human remains described above as indicated
Date Issued VOA I `( (S7. Registrar of Vital Statistics t s -/pp ka(
(s gnature)
District Number ,<TO 7 Place 14W C) �Ol��
I certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
wDate of Disposition "��—I f' Place of Disposition plpti Crc rya y
W (address)
N
to (section) (lot number) (grave number)
Q Name of Sexton or Person in Charge of Premises ctottiV S a -L.,
Z please print)
Signature Title Cro.i KAA v T
(over)
DOH-1555(02/2004)