Squiers, Katherine NEW YORK STATE DEPARTMENT OF HEALTH 4 - 1 l
Vital Records Section Burial - Transit Permit
::*i Name First Middle Last Sex
r:; Katherine M. Squiers Female
a Date of Death Age If Veteran of U.S. Armed Forges,
October 10, 2015 67 War or Dates n 10,
Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Indian River Nursing Home
Manner of Death pNatural Cause Accident Homicide Suicide Undetermined Pending
�
Circumstances Investigation
Medical Certifier Name a t n Title Undetermined
:;,: Address
cove sj 6tIerkSEo ,[s , Nig 1z2O1
';:;:; Death Certificate Filed District Number Register umber
err City, Town o i la G ? ftU) I le, .5-7a.5- 7
❑Burial Date Cemetery or Crematory
October 14, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
Cl)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I IPermit 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
�' Permission is hereby g anted to dispose of the human remai s descria abov s indicated.
:; .
:�::: Date Issued `3 /5 Registrar of Vital Statistics
?: (signature)
District Number ,5^M5---Place / jil,ta,
:•l:
I certify that the remains of the decedent identifi d ab a were disposed of in accordance with this permit on:
WDate of Disposition loI,5- ,r Place of Disposition .g� ...i (vn.4orw.
Ili
(address)
CO
IX (section) ,ry(lot nummer) (grave number)
pName of Sexton or Person in Charge of Premises r4, cwq-
z (please print)
W dt Signature /�- Title rePtiiidk
(over)
DOH-1555(02/2004)