O'Malley, Janet L r !
NEW YORK STATE DEPARTMENT OF HEALTH 3Z6,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Janet M. O'Malley Female
-. Date of Death Age , If Veteran of U.S. Armed Forces,
:''. Aril 25 2016 80 War or Dates
Place of Death Hospital, Institution or
4�i�jc, Town or WW1Lake Luzerne Street Address 82 Hawk Rd.
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Gaiotti-Grubbs MD
Address
.:- 102 Park Street,Glens Falls,NY 12801
fr Death Certificate Filed District Number Register Nu r
ti: City, Town or Village Lake Luzerne
L-. 9
D Burial Date Cemetery or Crematory
April 27, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
O Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:44:KS: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
A 53 Quaker Road,Queensbury,NY 12804
ff Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
::.: Permission is her by granted to dispose of the human m ns d crib d abo a as ' dicated.
....: Date Issued / Registrar of Vital Statistics i�� ���1 ---- ?
sigrfat6 re)
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/
'�'� District Number LS�P`-5� Place�i��P G-' e�, „J/
:::::::
I certify that the remains of the decedent identified ab were disposed of in accordance with this permit on:
W Date of Disposition (011b Place of Disposition 1W.J (,tar„-.
W (address)
U)
W (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises Zir.yNiol,
Z (pldase print)
W
Signature Title allvti}P2
(over)
DOH-1555(02/2004)