Gifford, Stella NEW YORK STATE DEPARTMENT OF HEALTH `' • I 71 G Z L
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
, Stella Rose Gifford Female
E,A4 Date of Death Age If Veteran of U.S. Armed Forces,
': August 31,2016 84 War or Dates n/a
cPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier
IName Title
;. Stephen Perazzelli,MD
Address
::" Glens Falls,NY
Death Certificate Filed District Number Registe JJ, ber
City, Town or Village Glens Falls,NY 5601 tt���f//
❑Burial Date Cemetery or Crematory
❑Entombment September 1, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZG ❑Removal and/or Held
and/or Address
H Hold
CO
0 Date lb, Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
If Permit Issued to Registration Number
N t Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury, NY 12804
, Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued q t i I / 6 Registrar of Vital Statistics W CR.A.. v\-Q__
(signatur
District Number 5 bQ j Place l7 (w?/ .S
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition V(1 I A. Place of Disposition r,t,,��.... C att......-
W (address)
co
ix (section) `/� (lot number) (grave number)
pName of Sexton or Person in Charge of Premises ai1p 1.-,..- 2."+1
Z I(please print
W Signature d �, Title (C01.47Del—
(over)
DOH-1555(02/2004)