Hipwell, Harriet 11/28/2016 15:01 5183773446 f ` LIGHTS FUNERAL HOME PAGE 01/02
-4 sP,
NEW YORK STATE DEPARTMENT OF HEALTH Burial Transit Permit
Vital Records Section
_ .4n..-
. Name First Middle Last Sex
Harriet Jane Hipwell Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 25,2016 87 War or Dates
Place of Death Villa a of Scotia Hospital, Institution or
Lei City, Town or Village Street Address Baptist Health Nursing& Rehab Center
0 Manner of Death�1 Natural Cause Accident Homicide Suicide Lri J Undetermined Pending
Circumstances Investigation
till Medical Certifier Name Title
C Ronald Otwon Physician acting on behalf of Attending Physician
Address
0?;14' 207 N. Ballston Avenue,Scotia, New York 12302
Death Certificate Filed Villa a of Scotia District Number ' Register Number
City, Town or Village 4620 119
I ElBurial Date Cemetery or Crematory v __�
�, November29,2016 Pine View Crematorium
11,4'b; Entombment,Address _
rIr®Cremation Queensbury, NY
Date Place Removed
Removal and/or Held
2 and/or Address
-t Hold
0 Date Point of
in 11 Transportation Shipment
a by Common Destination
foL. Carrier
'r' Date Cemetery Address
,! Q Disinterment
,s
ADate Cemetery Address
"' Rointerment
11
Permit Issued to Registration Number
tl'7 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
pi1Address
53 Quaker Rd.Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above -
Address
'
LEI
PI Permission is hereby granted to dispose of the human remai described ab as Indic ed.
If.,
`» Date Issued November 28,2018 Registrar of Vital Statistics 4.01 ,I (signature)
Ail
District Number 4620 Place Scotia, New York
I certify that the remains of the decedent identified above were disposed of in accordance`with this permit on:
Date of Disposition ///30 hi Place of Disposition t:Jiru.i (rwc ' _,
(address)
WI
rn
le (section) i l(lot number) c. (grave number)
Name of Sexton or Person in Charge of Pr mises list ,i 5enit�
�,, , (plse prlr#)
, Signature L/ an Title (gP IRF
(over)
DOH-1555 (02/2004)