Verbeck, Grace lk it 26.1
NEW YORK STATE DEPARTMENT OF HEALTH ` '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r Grace M Verbeck Female
c.v. Date of Death Age If Veteran of U.S. Armed Forces,
::1 March 29, 2015 95 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
r Joanna C.Erwin RPAC
.:': Address
rhr.
;.;.rr 100 Park Street,Glens Falls,NY 12801
:::::: Death Certificate Filed District Number Regre[ Duber
City, Town or Village Glens Falls 5601 ((p�m
❑Burial Date Cemetery or Crematory
March 31, 2015 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
co
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
PI Renterment Date Cemetery Address
."0. Permit Issued to Registration Number
f'.▪ Name of Funeral Home Regan Denny Stafford Funeral Home 01443
{f2; Address
;.:r 53 Quaker Road, Queensbury, NY 12804
of Name of Funeral Firm Making Disposition or to Whom
I
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
;: r Date Issued 3/ 31 / /5 Registrar of Vital Statistics LA) C,,t .A
; ; (signature)
iYr.
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition iiib1ic Place of Disposition Fni,(14) Grt►,—i
W (address)
U)
W (section) i (lot number) r (grave number)
QName of Sexton or Person in Charge of Premises A e,i &
Z (pldase print)
w
ASignature Title
(over)
DOH-1555(02/2004)