Case, Virginia NEW YORK STATE DEPARTMENT OF HEALTH - ..
Vital Records Section Burial - Transit Permit
.-: Name First Middle Last Sex
Virginia L. Case Female
: : Date of Death Age If Veteran of U.S. Armed Forces,
August 29,2014 71 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 188 Warren Street
Manner of Death I XI Natural Cause I I Accident pi Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Gary Scidmore,PA
Address
6970 State Route 8,Brant Lake,NY 12815
Death Certificate Filed District Number Register N ber
_ City, Town or Village Glens Falls,NY 5601 1!!//!!
. ❑Burial Date Cemetery or Crematory
September 2,2014 Pine View Crematorium
❑Entombment Address
El Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
O and/or Address
Hold
Cl)
0 Date Point of
NI I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ii:: 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
Remains are Shipped, If Other than Above
Address
` :: Permission is hereby granted to dispose of the human rains described ab ye as indi :ted.
iX Date Issued 04 Oa�0/ Registrar of Vital Statistics O(�Q_67— ,i ��`
(signature)
District Number 5601 Place Glens Falls,NY
:;a
I certify that the remains of the decedent identified above,were disposed of in accordance/wiith this permit on:
W Date of Disposition 413 j II Place of Disposition &Viz.., (.+�+4-torb
2 (address)
w
CO
CC
(section) of number) (grave number)
Qof Sexton or Person in Charge of Premises 'tot
�7>4141
Z (pleas print)
Name
w eLto "Signature '� Title CYaI1A1Lm
(over)
DOH-1555(02/2004)