O'Connor, Diane ... .., - 1 0 6-17
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Diane H O'Connor Female
Mi Date of Death Age If Veteran of U.S. Armed Forces,
07/06/2017 72 years War or Dates
I Place of Death Hospital, Institution or
kuZ City, -R.-MOO(UMW Glens Falls Street Address Glens Falls Hospital
3 Manner of Death Natural Cause ❑Accident ElHomicide ElSuicide ❑Undetermined ❑Pending
11 Circumstances Investigation
at Medical Certifier Name Title
James North M D
Address
100 Broad Street Glens falls, N Y 12801
Death Certificate Filed District Number Register Number
City, TdOfiet=XXX Glens Falls 5601 368
iiig❑Burial Date Cemetery or Crematory
07/07/2017 Pine View Crematorium
❑Entombment Address
[ICremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
M= Hold
(4
V Date Point of
pi❑Transportation Shipment
el by Common Destination
ei Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Alqonkin Street Ticonderoga, N Y
iiiiig Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
CC
LU
r" Permission is hereby granted to dispose of the human remains described above as indicated.
iM Date Issued 07/07/2017 Registrar of Vital Statistics W c1.Ajyv\sl_ 1")..A1\4e0--
.
(signature)
District Number 5601 Place Glens Falls)
1.:;`,. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fil f
▪ Date of Disposition '7110 in Place of Disposition rrtk.)-+ tn fo r i..i
(address)
In
0
CC (section) J(lot number) (grave number)
Name of Sexton or Person in Charge of Premises `+(re r S( 'fit
2 (ple a print)
I Signature }h
Title (174.4104
(over)
DOH-1555 (02/2004)