Dirga, Helen NEW YORK STATE DEPARTMENT OF HEALTH tic)
Vital Records Section Burial - Transit Permit
Name First Middle 1 Last Sex
Helen • D Dirga Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/05/2 12 87 years War or Dates
1 - ..- ofDealh Hospital, Institution or
Tow _V I�!.� X Clans F Street Address ParktitFriicTecerlilinNe1 1F,••-r o eath ', Natural Cause Accident ❑Homicide 0 Suicide ` ending
lij v Circumstances Investigation
Ili Medical Certifier Name Title
Q
Addresathew Varughcse M D
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
(City)Towi X Glens Falls 5601 407
LJ Burial ate • Cemetery or Crematory
❑Entombment 99;06/2012 Pik View Cemetery
Address
CJemation Queensbury, NY 12804
Date Place Removed
2❑and/or
Removal and/or Held
� Address
0
Hold
0 Date Point of
iZ 0 Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date . Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Hnme 01117
Address
P n Rnx 277 Fort Ann N Y 12527
Name of Funeral Firm Making Disposition or to Whom
•
14 Remains are Shipped, If Other than Above
Address
Iti
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/06/2012 Registrar of Vital Statistics tAkAjt
f i ,�
vv (sign,
District Number Place 5601 Glens Falls / Y /�0i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
III Date of Disposition 9-�/Z Place of Disposition RNo� v 0 ,�s„�
(address}
la
VI
CC (section) ` � ,f.✓/(lot number) (grave number)
CI �
Name of Sexton r P son - rge of Premises S /ih,�
(please print)10 1
Ui Signature Title C62Gs•1c a�}l /�S4$7'_
(over)
DOH-1555 (02/2004)