Martin, Janet 41370
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section , Burial - Transit Permit
Name First Middle Last Sex
Janet E. Martin Female
Date of Death Age If Veteran of U.S. Armed Forces,
4 May 5, 2017 76 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
Manner of Death Undetermined Pending
}s ❑X Natural Cause n Accident n Homicide Suicide n
Circumstances Investigation
Medical Certifier Name Title
,. Scott Biasetti MD
Address
100 Park St.Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY Li 6/ (,9g/
❑Burial Date Cemetery or Crematory
May 8, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date i Place Removed
ZZ n Removal I and/or Held
and/or Address
P" Hold
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O Date Point of
O.
• n Transportation Shipment
p 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
en
Address
.* 53 0 uaker Road, I ueensbur ,NY 12804
Name of Funeral Firm Making Disposition or to Whom
. Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described abo a�ir�jdjcated.
Date Issued 0 S70843/7 Registrar of Vital Statistics ////GG//e
:: _/ (signature)
District Number
SGO/ Place �jcAa `/, /tom
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tu Date of Disposition 5 Ito /17 Place of Disposition fin." w✓ L;i'ri`etJrlb•-
W (address)
CO
(section) /;/ (lot number) ( /, (grave number)
pp• Name of Sexton or Person in Charge of Premises C 'lf>sioPt r ✓d^�1 to
Z (ple a print)
W Signature 4 2 Title (REMrsDa_
(over)
DOH-1555(02/2004)