DeSantis, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH It 'S,b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth Talton DeSantis Female
Date of Death Age If Veteran of U.S. Armed Forces,
01/26/2012 89 years War or Dates
j - Place of Death Hospital, Institution or
Z City, Tow it Street Address
Glens Falls GI
0 Manner of eath❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ n ete mined ❑Pending
Circumstances Investigation
III Medical Certifier Name Title
0 Scott Biasetti M D
Address
100 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Towszlekyillmyx Glens rails 5601 34
['Burial Date Cemetery or Crematory
❑Entombment 0 /77/2012 Pine View Crematorium
Address
❑Cfemation (Jueenshury, NY 12804
Date Place Removed
g❑Removal and/or Held
and/or Address
i= Hold
ft}
0 Date Point of
ti El
Transportation Shipment
ES by Common Destination
N. Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
ail Address
•
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above •
a Address
IX
UI
P` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2012 Registrar of Vital Statistics k
(signal\j-jkir4ASk
ture)
District Number 5601 Place Glens Fails
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI p Disposition 'I �r 4-d d at._Date of Disposition �/Z��IZ Place of r� iw
(address)
Lu
MI
CC (section) t7 (lot numb (grave number)
Name of Sexton or Pe t•on in Charge Premises .c\ r ,1N,0n
(please print)
Signature !` � Title CR Vn RID ,
(over)
DOH-1555 (02/2004)