Love-Munoz, Lucille s v,
NEW YORK STATE DEPARTMENT OF HEALTH ,. .:Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lucille Love-Munoz Female
4�;; Date of Death Age If Veteran of U.S. Armed Forces,
N. September 10, 2016 80 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 12 Pinewood Rd.
Manner of Death X Natural Cause Accident 1 I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John Sawyer,MD
r Address
▪ 161 Carey Rd,Queensbury,NY 12804
?r Death Certificate Filed District Number Register Number
.▪ ' City Town or Village ueensbur OTh1 3�c�
❑Burial Date Cemetery or Crematory
September 12, 2016 Pine View Crematorium
❑Entombment Address
E1 Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
F_ Hold
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0 Date Point of
u) Transportation Shipment
a 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
r�, Address
53 Quaker Road,Queensbury, NY 12804
iYs, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
•.% Permission is hereby granted to dispose of the human re ains described above asi indicated.
.r. Date Issued CI I /�-1 1(Registrar of Vital Statistics �C,t,\9. q
asra_}.......,_
{p;:: (signature)
ti District Numbers Place ) �-] L�,� 1' &Lt/49,1. `,yam--,
.•. I certify that the remains of the decedent identified above were disposed of in accordance iti this permit on:
F-;
w R/M Date of Disposition 9(I3//( Place of Disposition Vuv„/ tr+LnctOCt-
2 (address)
W
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0 (section) ' (lot number) (grave number)
a Name of Sexton or Person in Charge of Premises A t.# �,10
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W IL 4.4.___. Title (M p�.Signature
(over)
DOH-1555(02/2004)