Coughlin, Mary r
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Barbara Coughlin Female
Date of Death Age If Veteran of U.S. Armed Forces,
gi August 18, 2018 79 War or Dates n/a
14 Place of Death Hospital, Institution or
• City, Town or Village Saratoga, NY Street Address Wesley Health Care Center
a Manner of DeathNatural Cause ❑Accident ❑Homicide [1 suicide ❑Undetermined ❑Pending
W Circumstances Investigation
la Medical Certifier Name itle
Eric Santell, NP
Address
Saratoga Springs, NY
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga, NY 4501
❑Burial Date Cemetery or Crematory
August 22, 2018 Pine View Crematory
❑Entombment Address
Cremation Quaker Rd, Queensbury, NY
Date Place Removed
Z Removal and/or Held
C ❑and/or
Address�
Hold
0 Date Point of
to ❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
❑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
Remains are Shipped, If Other than Above
', Address
Ui
Permission is hereby granted to dispose of the human remai cri ed ab e as indicated.
i Date Issued 8/22/2018 Registrar of Vital Statistics
(signature)
ni District Number 4501 Place City of Saratoga Springs, NY 12866
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition S-- S/ Place of Disposition piAc, t/ w c f:io Rio ry
(address)
Ui
U)
(section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises �`�^ Y �2" ��S
fir (please print)
• Signature / 0 Title C_,Cr,r or
(over)
DOH-1555 (02/2004)