Perrotte, Regiina i
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Regina K. Perrotte Female
0.
Date of Death Age If Veteran of U.S. Armed Forces,
a April 3, 2016 92 War or Dates
't Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
,a{ Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
'X Circumstances Investigation
.,?r, Medical Certifier Name Title
Stephen Perazzelli
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 1 D
❑Burial Date Cemetery or Crematory
April 5, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
Hold
CO
0 Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
i?r:; Permit Issued to Registration Number
g Name of Funeral Home Regan Denny Stafford Funeral Home 01443
% Address
:*. 53 Quaker Road, Queensbury,NY 12804
'ej,� Name of Funeral Firm Making Disposition or to Whom
; ; Remains are Shipped, If Other than Above
-;, Address
-a
Vim:; Permission is hereby granted to dispose of the human remains described above as indicated.
`: Date Issued L, 1 5 `2cJL, Registrar of Vital Statistics (A.1
(signatur
°ra: District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of inn accordance with this permit on:
W Date of Disposition 9 /12 //A Place of Disposition �jp� �
W (address)
co
ce (section) A(lot number (grave number)
GName of Sexton or Person in Charge of Premises L 4 fisEq�l.. A
Z (please print)
W
Signature Title attelifTV
(over)
DOH-1555(02/2004)