Stevens, Carol #15-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
Carol Russell Stevens Female
:A?:
Date of Death Age If Veteran of U.S. Armed Forces,
` January 29, 2017 98 War or Dates
4. Place of Death Hospital, Institution or
f7, City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
,Ff Manner of Death X Natural Cause U Accident ❑Homicide n Suicide 1-1 Undetermined n Pending
rF- Circumstances Investigation
':4: Medical Certifier Name Title
Kenneth France MD
{ Address
100 Broad Street
Death Certificate Filed District Number Register Number
City, Town or Village 0 l0
❑Burial Date Cemetery or Crematory
❑Entombment January 31,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
oand/or Address
Hold
)
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
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
411 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
r- Address
iS
{
I Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) 13 i ( / -7 Registrar of Vital Statistics CA.MY'- k,A-1--A,
(signa re)
7.
District Number 5 cD l Place 6 (.9, 11,\\5 r 0 ' '
g
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 213 f I) Place of Disposition miOtt.✓ ( naaoCiu‘....
W (address)
a
(section) il (lot number) r (grave number)
pName of Sexton or Person in Charge of Pr mises I i f J0n1(it
Z (please print)
Signature /� Title h -1111 i_
g l
(over)
DOH-1555(02/2004)