Piper, Drusilla NEW YORK STATE DEPARTMENT OF HEALTH' �J
Vital Records Section , Burial - Transit Permit
iigi Name First Middle Last Sex
Drusilla A. Piper Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/09/2017 82 years War or Dates
} Place of Death Hes-pita!, Institution or
City, TQ gp-MOW Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined El Pending
W. Circumstances Investigation
t Medical Certifier Name Title
pi Noelle Stevens M D
Address
100 Broad Street Glens Falls, N Y 12801
gi Death Certificate Filed District Number Register Number
City, Td( Xiatr XXC Glens Falls 5601 527
.7 O _
Burial Date Cemetery or Crematory
10/11/2017 Pine View Cematory
❑ _Entombment Address
i
[Cremation Queensbury, Ny
Date PIE. Removed
❑Removal and/ , Held
and/or
It Hold Address
0
0 Date Point of
Q Transportation Shipment
0 by Common Destination
ia Carrier
. []Disinterment Date Cemetery Address
Date CemeteryAddress
mi 0 Reinterment
Nii Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
_> Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
. Address
LU
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/11/2017 Registrar of Vital Statistics C, r
(sign ure)
District Number 5601 Place Glens Falls N L'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
rat
fd n
tf Date of Disposition to 1iz ID Place of Disposition ''Atyu.," u,.r, ,o,�
(address)Ul
��
0
Ce (section) (lot number)) (grave number)
Ci Name of Sexton or Person in Charge of Premises /Ar= Lkil2
( lease print)
144Signature G.-� - Title (Fftbt j
(over)
DOH-1555 (02/2004)