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Gifford, Sharon NEW YORK STATE DEPARTMENT OF HEALTH , , I Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sharon E. Gifford Female Date of Death Age If Veteran of U.S. Armed Forces, June 16,2012 61 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 11 1/2 First Street ` Manner of Death n Undetermined n Pending X Natural Cause Accident Homicide Suicide Circumstances Investigation Medical Certifier Name Title Dr North,MD Address Glens Falls,NY Death Certificate Filed District Number Regis* .umber City, Town or Village Glens Falls,NY 5601 _ d7 ❑Burial Date Cemetery or Crematory June 19, 2012 Pine View Crematory D Entombment Address ©Cremation Quaker Road, Queensbury,NY 12804 _ Date Place Removed Z ❑Removal and/or Held and/or Address H Hold N 0 Date Point of N ❑Transportation Shipment p by Common Destination Carrier El Disinterment Date Cemetery Address DReinterment 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 1 t Permission is here y ranted to dispose of the human re ains des ibed abor as indica, d. Date Issued • / ?G/�-Registrar of Vital Statistics R._ .f 172 & 0f ( (signature) District Number 5601 Place Glens Falls,NY /o?�d/ I certify that the remains of the decedent identified above were d' posed of in accordance with this permit on: Z W Date of Disposition 4,11$I It Place of Disposition RaUw,J �► t JtL... W (address) Cl) pre (section) Acisi,filflo_t number) c (grave number) Name of Sexton or Person in Charge f Premises 5�. . W (Please print) Signature 41-, Title CKfi/'M-�,Ot (over) DOH-1555(02/2004)