Dunn, Regina NEW YORK STATE DEPARTMENT OF HEALTH
0 53b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Regina M. Dunn Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/30/2018 68 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Undetermined PendingHy
Circumstances Investigation
Medical Certifier Name Title
William Cleaver MD
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 320
'El Burial Date Cemetery or Crematory
07/02/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address 1
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
*El❑Reinterment Date Cemetery Address
`; Permit Issued to Registration Number
Name of Funeral Home Miller Funeral Home 01199
At
Address
6357 Nys Rte#30, Indian Lake, New York 12842
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 07/02/2018 Registrar of Vital Statistics Men A Curtis(ECectronicalty Signed)
(signature)
District Number 5601 Place Glens Falls, New York
re I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 11 t Ili Place of Disposition `'rtki-'
(address)
(section) (lo1number) (grave number)
Name of Sexton or Person in Charge of Premises (p/easd[[[/14�r,T�Lprint)
3 e^n�'
Signature �u Title
COMP&
(over)
DOH-1555 (02/2004)