Manzella, Teresa NEW YORK STATE DEPARTMENT OF HEALTH `. # /3.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Teresa Manzella Female
Date of Death Age If Veteran of U.S. Armed Forces, N/a
February 7,2018 75 War or Dates
h• Place of Death Hospital, Institution or
Z City, Town or Village Queensbury,NY Street Address 6 Mohawk Trail
W Manner of Death a Natural Cause Accident Homicide n Suicide n Undetermined U Pending
Circumstances Investigation
w Medical Certifier Name Title
• Aqeel Gillani,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
February 8,2018 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
ZO C Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
O.
❑Transportation Shipment
'p by Common Destination
Carrier
El
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
e. 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
Remains are Shipped, If Other than Above
Address
tti
- Permission is hereby granted to dispose of the human r ' s des abov indicated.
Date Issued D-Bol9 Registrar of Vital Statistics
/ (signet
District Number �(y,�;� Place '/(j p
I certify that the remains of the decedent identified abo were disposed of in acciance with this permit on:
ui Date of Disposition ZI 9 ig Place of Disposition
W (address)
N
(section) A (lot numbs (grave number)
pName of Sexton or Person in Charge of Premises (,(r,,tp�- c�y�►�
Z ( lease print)
W
Signature CJ -24
Title
(over)
DOH-1555(02/2004)