Kopper, Joan /a 14
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
.i'?' Name First Middle Last Sex
: : Joan I. Kopper Female
'j' Date of Death Age If Veteran of U.S. Armed Forces,
f October 9, 2015 78 War or Dates NA
Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address Stanton Nursing & Rehab Centre
if Manner of Death X Natural Cause Accident [ I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
'>;;; Roslyn Socolof MD
�:rti Address
:r 152 Sherman Ave. Glens Falls,NY 12801
f Death Certificate Filed District Number Register Number
';:; City, Town or Village Town of Queensbury 5to 51 lD {-
❑Burial Date Cemetery or Crematory
El Entombment October 13, 2015 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F Hold
N
0 Date Point of
N ( I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ai Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
: j Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1.f Remains are Shipped, If Other than Above
Address
', Permission is hereby granted to dispose of the human remains described above as indicated.
{.
Date Issued l0(t 3 1, (71S Registrar of Vital Statistics . l?e. Ak..x _�.}\.r
(signature)
District Number 5.4 51-7 Place Q v e c 7,'1 S U/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1a/lqN- Place of Disposition
2 (address)
U)
QCL (section) (lot number) (grave number)
/►/Name of Sexton or Person in Charge of Premises 6 tir7�1�(t.r .�o,.,*
Z Y (please print)
W
Signature �-- Title rw1 K
(over)
DOH-1555(02/2004)