Harper, Verna t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Verna A. Harper Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 17,2014 63 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address GlensFalls Hospital
p Manner of Death n Natural Cause n Accident n Homicide n Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
James North Dr.
Address
100 Broad St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Nu ber
City, Town or Village Glens Falls 5601 3
❑Burial Date Cemetery or Crematory
January 21, 2014 Pine View Crematory
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
N
0 Date Point of
Transportation Shipment
p by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
E
Reinterment 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
tom- Remains are Shipped, If Other than Above
2 Address
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )l 2. 11 ) l-, Registrar of Vital Statistics LA7C -sk. W
(s nature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�� �^
ill Date of Disposition I/64)`.1 Place of Disposition #CJ U.a..! rvebtA,.
i (address)
W
N
(section) (lot numb-- (grave number)
pName of Sexton or Person in Charge of Premises doi7211,
Z (please print)
W (J .
Signature /��__. Title Ci�f�+ry0�
(over)
DOH-1555(02/2004)