Russell, Grace NEW YORK STATE DEPARTMENT OF HEALTH # /31
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Grace M. Russell Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 26, 2015 87 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death n Natural Cause Li Accident Homicide n Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Robert Sponzo,MD
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
March 2, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z
Fi❑Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit 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
H Remains are Shipped, If Other than Above
2; Address
re
Permission is hereby granted to dispose of the human remains described abovq as indicated.
Date Issued 31 2- / 15 Registrar of Vital Statistics CA Cat, "12_,
(sign ure)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition Air Place of Disposition
` I S (address)
(section) (lot number)e. (grave number)
QName of Sexton or Person in Charge of Premises /64.-trig•-• enr+t
Z (please print)
W
Signature Title CdAc
(over)
DOH-1555(02/2004)