Copeland, Christine -,
NEW YORK STATE DEPARTMENT OF HEALTH �cli'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Christine Copeland Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/03/2014 53 years War or Dates
W 'o-, of Death Hospital, Institution or
ovilOGIXVOMXX Glens Falls Street Address Glens Falls, N Y 12801
W Manner of Death `� t, atural Cause ❑Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
iW Medical Certifier Name Title
CI Suzanne M. Rayeski M.D.
Address
100 Park Street Glens Falls, NY 12801
D th Certificate Filed District Number Register Number
City To XX XJIX (X Glens Falls 5601 511
LJBurial Date Cemetery or Crematory
['Entombment Address
Pine View Crematory
Address
Qremation Queensbury, NY
Date Place Removed
9, ❑Removal and/or Held
and/or Address —
~ Hold
CA
0 Date Point of
ftQ Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00448
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
1;-i-i Remains are Shipped, If Other than Above
'; Address
t
III
II' Permission is hereby granted to dispose of the human remains describe above a indi t .
Date Issued 11/06/2014 Registrar of Vital Statistics � LI ' -
(signature)
District Number 5601 Place Glens Falls 7/..// /d-gt}/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �^
Ili Date of Disposition ii/jo��y Place of Disposition �,s� ti_ r,_dos
a (address)
I
tfl
CC (section) J� (lot number) (grave number)
Ct
p Name of Sexton or Person i Charge of remises G"1t1 3fM4/
(please print)
ilii Signature k") Title ciS oft colt
V (over)
DOH-1555 (02/2004)