Studnicky, Nancy ; tcD
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy E. Studnicky Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 14,2015 , 60 War or Dates
Place of Death Hospital, Institution or
: City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
M, Medical Certifier Name Title
O Daniel Sooriabalan
Address
HH)FIN
Death Certificate Filed District Number Regis�,e�rt ber
City, Town or Village Glens Falls 5601 / 1
❑Burial Date Cemetery or Crematory
August 17,2015 Pine View Crematory
Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal nd/or Held
and/or Address
Cl) Hold
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment. Date Cemetery Address
x Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
` Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Ce
tL1.
Permission is hereby ranted to dispose of the human remains de ribed ab e a d'cated.
Date Issued %7 Registrar of Vital Statistics id
(signature)
District Number j�Q/ Place 11.::::Y14 yY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition glo(tc Place of Disposition Li.--, �,.m-gldr_.-
W (address)
CO
IL (section) d� ` (lot n ber) (grave number)
pName of Sexton or Person in Charge of Premises G4., ja*
Z (please print)
W Signature Title rittAnclit
(over)
DOH-1555 (02/2004)