Purvis, June '/7
NEW YORK STATE DEPARTMENT OF HEALTH �'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
an
June E. Purvis Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 13, 2017 89 War or Dates NA
,, : Place of Death Hospital, Institution or
rCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause ❑Accident n Homicide Suicide 1-7 Undetermined n Pending
Circumstances Investigation
P.€_. Medical Certifier Name Title
10 Matthew Caru•hese 4iII
Address 100 Park St. Glens Falls, NY
At Death Certificate Filed District Number /� I g Re ister Number—)
City, Town or Village Glens Falls, NY C` `D9
❑Burial Date Cemetery or Crematory
❑Entombment January 17,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:i. Permit Issued to Registration Number
Name of Funeral Home Re.an Denn Stafford Funeral Home 01443
ri Address
53 1 uaker Road, 1 ueensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
IA Remains are Shipped, If Other than Above
Address
I
Permission is hereby granted to dispose of the human remains described above as indicated.
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•{r Date Issued I t t-1120 17 Registrar of Vital Statistics ��ve
(signatur
r District Number S k) i Place G c..\1MS \\\C,1, -'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p ,,^^
Date of Disposition 11l3 if n Place of Disposition .,ru ,;.✓ t;1c(orzr�
W (address)
CO
rt (section) �!� jlot number) (grave number)
pName of Sexton or Person in Charge of Pre ises ( rfrat'1�
Z (lease print)
W
Signature Z M Title !!F MttePL
(over)
DOH-1555(02/2004)