Griffen, Theresa NEW YORK STATE DEPARTMENT OF HEALTH # 2U
Vital Records Section
. :.�.,, Burial - Transit Permit
Name First Middle-- Last Sex
Theresa Mae Griffen Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/22/2012 51 years War or Dates
H Place of Death Hospital, Institution or
W City, Town or Village Town Of Milton Street Address 3461 Galway Road
0 Manner of Death Natural Cause 0 Accident ❑Homicide 0 Suicide ❑Undetermined El Pending
W Circumstances Investigation
ill Medical Certifier Name Title
CI John Delmonte Jr. MD
Address
3 Care Lane Saratoga Springs, New York 12866
Death Certificate Filed District Number Register Number
: X 1cXTown °NOW Milton 4561 18
❑Burial Date Cemetery or Crematory
05/23/2012 Pine View Cemetery
['Entombment Address
]Cremation Queensbury N Y
Date Place Removed
Z Removal and/or Held
❑and/or Address
F= Hold
U
0 Date Point of
ti
7 Transportation Shipment
i ❑
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette St, Queensbury, N Y
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IZ
ILI
Permission is hereby granted to dispose of the human r -ns describ ab ye as indic te\d.
Date Issued 05/23/2012 Registrar of Vital Statist Q,
(signature)
Eii District Number 4561 Place Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t"
2
ill Date of Disposition S 174111 Place of Disposition ei?(LW Ct ctpr),__
a (address)
LU
U)
CC (section) (lot number) r (grave number)
Ci Name of Sexton or Pe on in Charg of Premises /c°st �n �ta,��}'
Z 74L
w (please print)
S14 ignature Title * Q1O r
9
(over)
DOH-1555 (02/2004)