Lantz, Marie NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
MI Marie Ann Lantz Female
Date of Death Age If Veteran of U.S. Armed Forces,
iiiiiiiii December 28,2016 84 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address 17 Highpoint Drive
Manner of Death ❑X Natural Cause n Accident n Homicide Suicide n Undetermined Pending
DF
Circumstances Investigation
'' Medical Certifier Name Title
Alicia Earley MD
ioi
Address
161 Carey Rd.Queensbury,NY
Death Certificate Filed District Number RegistejNumber
City, Town or Village Town of Queensbury 5657 I
❑Burial Date Cemetery or Crematory
❑Entombment January 2,2017 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ 0 Removal and/or Held
and/or Address
N Hold
C
0 Date Point of
IL N ❑Transportation Shipment
3 by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
gili Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Al Address
ji,- 53 I uaker Road I ueensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;r Address
Permission is hereby granted to dispose of the human re ains described abo e as indibated.
Date Issued6.0)(i.rtegistrar of Vital Statistics 2.Ls--_.
To (signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance(��! with this permit on:
Z DispositionII1Jii DispositionZetJt �ft l
Date of Place of ,. mw �(��,�,
W (address)
N
rt (section) //lot number) (grave number)
ca Name of Sexton or Person in Charge of Premises _ /GA f ,Sf"iiq-
Z �1p (ple se print)
W Signature L.f 4 Title c mtinit
(over)
DOH-1555(02/2004)