Hungerford, Beryl ' tiy2_
NEW YORK STATE DEPARTMENT OF HEALTH i
Vital Records Section Burial - Transit Permit
?f : Name First Middle Last Sex
%:. Beryl Orra Hungerford Female
%'`> Date of Death Age If Veteran of U.S. Armed Forces,
. June 5, 2017 82 War or Dates
'< Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
A Manner of Death n Natural Cause n Accident n Homicide l i Suicide Undetermined Ti Pending
Circumstances Investigation
Medical Certifier Name Title
�` Gwendolyn Morris-Dickinson
` Address
f 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
:r: City, Town or Village 3 1 � i
Y 9 Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment June 7, 2017 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO n Removal and/or Held
and/or Address
! Hold
Cl)
0 Date Point of
yTi Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Ti Reinterment Date Cemetery Address
r: Permit Issued to Registration Number
:f Name of Funeral Home Regan Denny Stafford Funeral Home 01443
.. Address
4r
, 53 Quaker Road, Queensbury,NY 12804
: Name of Funeral Firm Making Disposition or to Whom
''' Remains are Shipped, If Other than Above
I._ Address
IA
01 Permission is hereby granted to dispose of the human remains described above as indicated.
r=. Date Issued U1 1 d 2.C(J Registrar of Vital Statistics L'-) LAJLAYix
;•r% (sign$cure)
•:'iiiiif District Number 5601 Place Glens Falls) At y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition ,[elf r7 Place of Disposition g,eiiitti4 & ,*Dr(o*-,
ill
(address)
CO
OC (section) (lot number) (grave number)
00 Name of Sexton or Person in Charge of Premises gr.:i ., .a/,�-
Z (pl se print)
W Signature �( Title (lain r7LJ/L
(over)
DOH-1555(02/2004)