Mirasola, Flora NEW YORK STATE DEPARTMENT OF HEALTH I JSr
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r Flora Mirasola Female
tiDate of Death Age If Veteran of U.S. Armed Forces,
: March 3, 2015
;ff 85 War or Dates
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Place of Death Hospital, Institution or
City, Town or Village Glens Falls, Street Address The Pines At Glens Falls
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
; Circumstances Investigation
Medical Certifier Name Title
Melissa Decker MD
;.•{
e Address
f•., 9 Carey Road,Queensbury,NY 12804
"'{'s Death Certificate Filed District Number Register Number
1 City, Town or Village Glens Falls 5601 000
❑Burial Date Cemetery or Crematory
❑Entombment March 5, 2015 Pine View Crematory
Address
EI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
f' Hold
Cl,
0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
pi Disinterment Date Cemetery Address
I I Reinterment
Date Cemetery Address
L; :; Permit Issued to Registration Number
• :: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
{.r Address
r 53 Quaker Road, Queensbury,NY 12804
rrrti Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ti
;•r,:;:; Permission is hereby granted to dispose of the human remains described above as indicated.
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Date Issued 3 J'S J Registrar of Vital Statistics �M
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•P•?:': District Number 5601 Place Glens Falls A/ '7.'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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w Date of Disposition 31LJIb- Place of Disposition r. _� e.
W (address)
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Le
0 (section) (lot nu/rrb (grave number)
p Name of Sexton or Person in Charge of Premises ,
Z (please print)
W
Signature A Title (MA
(over)
DOH-1555(02/2004)