Antos, Diana NEW YORK STATE DEPARTMENT OF HEALTH + 'u l08
Vital Records Section Burial - Transit Permit
T'': Name First Middle Last Sex
Diana Antos Female
iDate of Death Age If Veteran of U.S. Armed Forces,
el May 29,2015 - 71 War or Dates n/a
'I
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide n Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
44
Robert Sponzo MD
Address
ti Glens Falls,NY
% Death Certificate Filed District Number Register Number
11
�%r City, Town or Village Glens Falls 5601 --,5 7 S
El Burial Date Cemetery or Crematory
❑Entombment June 1, 2015 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
f:, Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
`% Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
'f Remains are Shipped, If Other than Above
Address
;,,ff Permission is hereby ranted to dispose of the human emains d:scribed a ove as i icate .
RI
>; Date Issued Registrar of V' I Statistics �/ -, ,
f ( (signature
District Number / Place , `7/
I certify that the remains of the decedent identified above wer, disposed of in accor nce with this permit on:
Z
W Date of Disposition G/Z//S' Place of Disposition ni U,,,,, ( -i--
(address)
co
ce (section) (lot numb°') (grave number)
pName of Sexton or Person in Charg of Premises A Jcv
`Z please print)
Signature Title lltn»ttrq.
(over)
DOH-1555(02/2004)