Muller, Victoria rr 17z'l
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
's• Name First Middle Last Sex
Victoria A. Muller Female
e. Date of Death Age If Veteran of U.S. Armed Forces,
April 13, 2016 94 War or Dates
•.:: Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death
X Natural Cause 1 I Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
M• edical Certifier Name Title
gi Sean Bain MD
:'r: Address
r.r 100 Park Street
D• eath Certificate Filed District Number //__ / Register umber
err.s City, Town or Village �CC� / r-, d 3
❑Burial Date Cemetery or Crematory
April 15, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N I I 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
:; Address
53 Quaker Road, Queensbury, NY 12804
'r:. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress
; ▪.. Permission is here y granted to dispose of the human re ains described abov a indicated.
"r.:, Date Issued (�� J� DUI(a Registrar of Vital Statistics � iYz r c7/2/Y7�
;.; (signature)
r.• District Number 660/ Place /-;-4 :&</' 77(/
I certify that the remains of the decedent identified above were disposed of in accordance wit his permit on:
Z /�
W Date of Disposition II if S'Ib Place of Disposition Zt I., r tL.,.
2 (address)
W
U)
W (section) diY45,,,(lot num er) (grave number)
0p Name of Sexton or Person in Charge of Premises !M11
Z (please print)
W 7_
Signature %iv- Title
(over)
DOH-1555(02/2004)