Flint, Barbara t� WSJ r I. r ?S4s
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
BARBARA M. FLINT Ftrrale
Date of Death Age If Veteran of U.S. Armed Forces,
Axil 15, 2014 77 War or Dates n/a
Fi'. Place of Death Hospital, Institution or
City, Town or Village Glans Falls, NYtil Street Address Glens Falls Hospital
Manner of Death1 Natural Cause ❑Accident Homicide Suicide Undetermined Pending
tti
0 Circumstances Investigation
til Medical Certifier Name Title
0. Imo'1Vth, MD
.Address
Quasnslairy, NY
`i: Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
Aril 18, 2014 • Pire View Crarat ry
`'`` []Entombment Address
Cremation Quaker RI¢any, NY
Date Place Removed
Removal and/or Held
7❑and/or
Address
Hold
- 0 Date Point of
CL Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Si gl�rn gfllivan Potter Ftxreral Hare 01596
Address
407 Pay R3 Qusenssbury, NY 12804
10 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
te
lid
Permission is hereby granted to dispose of the human remains described above as ' i ted.
Date Issued 4/18/2014 Registrar of Vital Statistics , I / ?-
(signature)
District Number 5601 Place City of Glen Falls, NY 12801
..:;>. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to kr
Date of Disposition �ltiIII Place of Disposition ZtaiL ram' y,,.-
(address)
ill
IX (section) (lot number (grave number)
Name of Sexton or Person . Charge of Premises dewstiL, 1%r0 i'
► 7 (Please print)
Signature Title C
(over)
DOH-1555 (02/2004)