Haseltine, Joan NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
iiiii Name First Middle Last Sex
Joan Haseltine Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 9, 2015 82 War or Dates NA
I.::: Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury Street Address The Stanton Nursing & Rehab Center
t i Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
itUi Circumstances Investigation
Medical Certifier Name Title
gl Suzanne Blood MD
Address
iiiii 152 Sherman Avenue Glens Falls,NY
,;:;; Death icate Filed District Number Register Number
u
'_ City own Village � emi ,&&t s(tcq I(0 3
❑Burial Date J Cemetery or Crematory
October 1g, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
i*;+; Remains are Shipped, If Other than Above
Address
g
Permission is hereby granted to dispose of the human r i es, .. as indicated.
,�. :Date Issued 10., t?- Is Registrar of Vital Statistics lt.iL
(signature)
iiiii District Number �(.61 Place �0a4/1 ?uai4 L.LA
I certify that the remains of the decedent identified ab e were disposed of inrdance with this permit on:
WDate of Disposition to/la/lc Al.,la `Place of Disposition t, ' ,,,t{a,.,�
W (address)
U)
0 (section) j (lot numbe)� (grave number)
pName of Sexton or Person in Char of Premises L Ijr.. \,.g
Z lease print)
Wa:
Signature Title igkM4/11.
(over)
DOH-1555(02/2004)