Graves, Elaine NEW YORK STATE DEPARTMENT OF HEALTH S(1 D
Vital Records Section `Burial - Transit Permit
Name First Middle Last Sex
Elaine Audrey Graves Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2016 91 War or Dates NA
Place of Death
Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
7 Manner of Death X Natural Cause Accident piHomicide Suicide n Undetermined Pending
Circumstances Investigation
', Medical Certifier Name Title
Sean Bain MD
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Registe Number
City, Town or Village Glens Falls,NY S�pQ/ 190.E
❑Burial Date Cemetery or Crematory
El Entombment December 5, 2016 Pine View Crematorium
Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
E Hold
Cl)
0 Date Point of
35 n Transportation Shipment
is by Common Destination
Carrier
Ti 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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
VI
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued ) -).1 5!20/Registrar of Vital Statistics W o fl ' vA/_ V,04
(signature)
District Number 5 b 0 , Place 6 1. �5 co, V\ 5 Ai v
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ;;�� /'
LU Date of Disposition let Jib Place of Disposition 4 n uM. `roscioriv,,.
2 (address)
W
Cl)
QCL (section) / (lot numb�er (grave number)
Name of Sexton or Person in Charge of Premises /Lr, Jo'i?ir
Wlease print)
Signature Title (l E4i b/2
(over)
DOH-1555(02/2004)