West, Victoria If l01
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
rt Name First Middle Last Sex
Victoria B. West Female
Date of Death Age If Veteran of U.S. Armed Forces,
r!= February 14, 2014 90 War or Dates
I Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death n Natural Cause n Accident n Homicide ❑Suicide U Undetermined n Pending
Circumstances Investigation
. Medical Certifier Name Title
A Roslyn Socolof Dr.
Address
Ni 42 Gurney Lane,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 ‘3
❑Burial Date Cemetery or Crematory
February 18, 2014 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E Hold
Cl)
O 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
R 53 Quaker Road, Queensbury,NY 12804
E>= Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
Address
As'
Permission is hereby granted to dispose of the human rem escri; = • • • •- in 'cated.
gia
gi Date Issued D_•--1 - j1 Registrar of Vital Statistics V r �•,
(signatur
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z -,
w Date of Disposition of rt Ay Place of Disposition �Jt,,, �t-4+f,,_
2 (address)
W
CO
O (section) diOsill
(lot umber) ( (grave number)
Q• Name of Sexton or Person in,Charge of Pr mises r nx'i1
Z41 (pase print)
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Signature Title C 6441I'Z
(over)
DOH-1555(02/2004)