Stiffel, Kathryn 1 „• it 4
1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r' Female
'�"` Stiffel
:�< Kathryn
`ii
: Date of Death 1 Age If Veteran of U.S. Armed Forces,
gl.,.' 4/5/2011 1 8•3
War or Dates no
`$'. Place of Death Hospital, Institution or
Town of JX Johnsburg Street Address Adirondack Tri-County Nursing Home
Manner of Death71-1
Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
} Medical Certifier Name ` Title
C 'IlDrylas Ida .rr1n1--or\ R P A-
Address
{ North Creek,NY
V`' Death Certificate Filed District Number Register Numbep
k� s6 S
Otty, Town o� Johnsburg
Date i Cemetery or Crematory
❑Burial 4/7/2011 1 Pine View Crematory
Address
Cremation Queensbury,NY
Date Place Removed
g❑Removal i and/or Held
and/or ! Address
US Hold
0 1 Date 1 Point of
44 Q Transportation I Shipment
G by Common I Destination
Carrier
0 Disinterment Date { Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to I Registration Number
r , Name of Funeral Home Miller Funeral Home I 01222
''' Address
PO Box 718, Indian Lake, NY 12842
`}'' Name of Funeral Firm Making Disposition or to Whom
h.
Remains are Shipped, If Other than Above
Address
`: Permission is hereby granted to dispose of the human rema' s described bo s indicated.
1
0
'. . Date Issued 4- ?-0200 Registrar of Vital Statistics C2.4-10-A__
l/
s nature)//
� District Number 6-6O S j Place /�J d CI r7 S Oil
I certify that the remains of the decedent identified above were disposed of in II accordance with this permit on:
,, �
hi Z Date of Disposition i-�`It Place of Disposition l (nj o at.4 C rlm<f dt ►�v
(address)
W
to
(section) cilo� t number (grave number)
g L Name of Sexton or Person in Charge f Premises o31v*N.- -. h,ii4
2 (please print) t
W Signature Title (14;�M 470 C
DOH-1555 (10/89) p. 1 of 2 VS-61