Weiss, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH - fr
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Evelyn M. Weiss Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 11, 2012 86 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death X Natural Cause l I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
0 E.Palling,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 62
❑Burial Date Cemetery or Crematory
February 14, 2012 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
f" Hold
N
O Date Point of
NI I Transportation 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 Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
I-- Remains are Shipped, If Other than Above
2 Address
Permission is he eb .granted to dispose of the human r mains d scribed above as ndic• ed.
Date Issued j . 1, . Registrar of Vital Statistics g_f��2` 1 7—C
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
w Date of Disposition clo Ill Oa_ Place of Disposition
(address)
N
(section) (lot number- (grave number)
• Name of Sexton or Per on in Charge o Premises G I,r k 4,-- -Ntifrtif
(please print)
W
Signature 7c� Title CV1.�vrntUltv
(over)
DOH-1555(02/2004)