Small, Barbara A -#-xs-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First
Middle Last Sex
° Barbara F. Small Female
ti°.r
rr• Date of Death Age If Veteran of U.S. Armed Forces,November 12, 2014 76 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 18 Amy Drive
▪ Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Aqueel Gillanii Dr.
i Address
102 Park Street,Glens Falls,NY 12801
r▪ ,, Death Certificate Filed District Number Register Number
° City, Town or Village Moreau 4562 3
❑Burial Date Cemetery or Crematory
El Entombment November 14, 2014 Pine View Crematorium
Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
U)
0. Date Point of
u) 1 'Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
.;.° Permit Issued to Registration Number
'::,':,..3. 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
IQ
"" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued /ii j ail y Registrar of Vital Statistics /`[ u -'.-
,:.;r (signature)
., District Number 4562 Place Moreau 5j �@cy n of CAS d s ' , 2ki1c,�i12 Ni
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1-
Date of Disposition vain Place of Disposition I meU,,. 4o,:�.`
2 (address)
iti
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O (section) APlot number (grave number)
Q Name of Sexton or Person in Charge of Premises G k.~ i`r` ,_ wt#
Z
Ili (p/ ase print)
Signature / Title ClKIMhP4
(over)
DOH-1555(02/2004)