Etu-Stoughton, Denais NEW YORK STATE DEPARTMENT OF HEALTH ,, , its
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Denais Margaret Ann Etu-Stoughton Female
Li Date of Death If
e If Veteran of U.S. Armed Forces,
05/10/2014 ��� &years War or Dates
1- Place of Death Hospital, Institution or
6 City, TowmgoViPORXX Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause ❑A,ccident ❑Homicide ❑Suicide ElUndetermined ❑Pending
UILI Circumstances Investigation
w Medical Certifier Name Title
fl Michael Lieberth M D
Address
17 Baywood Drive Queensbury, N Y 12804
Death Certificate Filed District Number Register Number
City, TowAVOOVIRMXX Glens Falls 5601 226
❑Burial . Date - Cemetery or Crematory
❑Entombment 05/12/2014 Pine View Crematorium
Address
❑Cremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 ❑and/or Address
H Hold
Cl)i
O Date Point of
): 0 Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home ii a i1 _ tuti I L *AL 0/079
Address PI
`6L bU fair %N-11-I'�- 1 P I 1 S -
...iii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
to
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/12/2014 Registrar of Vital Statistics lAj c ,Nj .. rg
(sign re)
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:
L`'
t• Date of Disposition S`it-I� Place of Disposition ,1.,,.� wr-
(address)
tii
CC (section) (lot numt ) (grave number)
Name of Sexton or Person An Charge of Premises Pm S
r (please print) II
Signature L. Title tiN ill WV
(over)
DOH-1555 (02/2004)