Grimes, Gretta +[ .,t►
NEW YORK STATE DEPARTMENT OF HEALTH ifq
Vital Records Section Burial - Transit Permit
s:.: Name First Middle Last ' Sex '
t: Gretta Luella Grimes Female
ffra Date of Death Age If Veteran of U.S. Armed Forces,
March 9, 2016 93 War or Dates n/a
ti
Place of Death Hospital, Institution or
City, Town or Village Chester,NY Street Address 13A Marshall Fish Road
Manner of Death
I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
I
Medical Certifier Name Title
R Dr.Daniel Way,MD
Address
Indian Lake,NY
, ;r Death Certificate Filed District Number Register Number
ism' City, Town or Village Chester,NY
❑Burial Date Cemetery or Crematory
March 11,2016 Pine View Crematorium
❑Entombment Address
CI Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
9. and/or Address
• Hold
CD
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
::;v Permit Issued to
. Registration Number
ea
..f�;: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:° ? Address
®a ' 53 Quaker Road, Queensbury,NY 12804
r:: Name of Funeral Firm Making Disposition or to Whom
'ii
' Remains are Shipped, If Other than Above
Address
'. Permission is hereby granted to dispose of the human re ills described above as indicated.
,-.-
°stir Date Issued 03 f/D f/(p Registrar of Vital Statistics 03\4014A) ---
,''..0. `signature)
•;:,: District Number 5(p5� Place ot,, Ci(te'S er- tAl'�1.- , CO t,c vt1-1
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z C ton
W 6 Rot U Date of Disposition 3/11�� Place of Disposition t.,
2 (address)
W
CO
Ce (section) duilyisiN
(lot nurser) (grave number)
Q Name of Sexton or Person in Charge of Premises iltMit
Z (pleaseprint)Signature Title atbuitia.
(over)
DOH-1555(02/2004)