Gagliardi, Patricia -11
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia Ellen Gagliardi Female
Date of Death Age If Veteran of U.S. Armed Forces,
November 20,2014 77 War or Dates n/a
Place of Death Hospital, Institution or
3 City, Town or Village Queensbury, NY Street Address Stanton Nursing& Rehab Centre
Manner of Death 0 Natural Cause I I Accident ❑Homicide ❑Suicide U Undetermined n Pending
Cif Circumstances Investigation
A Medical Certifier Name Title
9, Roslyn Socolof,MD
Address
: - Glens Falls,NY
Death Certificate Filed District Number Register Number
,,,; City, Town or Village Queensbury,NY 5657 153
❑Burial Date Cemetery or Crematory
D Entombment November 24, 2014 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
1 Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
flt
41,
Permission is hereby granted to dispose of the human i s d a v s indicated.
Date Issued 1 a1-1 4 Registrar of Vital Statistics D
(signs re
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 1(/-4 f(y Place of Disposition 474,ki—/ ,.,}ter...,
W address)
co
w (section) 1d'
*lease
(lot numb ) (grave number)
QName of Sexton or Person in Charg of Premises a1W print)
Signature Title 17cigZ
(over)
DOH-1555(02/2004)