Bashaw, Doris NEW YORK STATE DEPARTMENT OF HEALTH, ♦
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
r▪ : Doris M Bashaw Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 14, 2014 84 War or Dates
1". Place of Death Hospital, Institution or
• City, Town or Village Glens Falls Street Address 217 Ridge Street
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi Paul R.Filion Dr.
Address
3 Irongate,Glens Falls,NY 12801
Death Certificate Filed District Number Registeir mber
City, Town or Village Glens Falls 5601 [[77�'
❑Burial Date Cemetery or Crematory
March 17, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
E Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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 remains described above as indicated.
Date Issued 3 1 a —) I I LI Registrar of Vital Statistics Cx.Ai}- Q, w
(signature
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:
Z
W Date of Disposition3-16--1q Place of Disposition i h}e_ v( (�
2 (address)
W
CO
Q0 (section) �- (lot number) (grave number)
Name of Sext or erso i Charge of Premises )C.a-4 ho,.,) \es✓1 a
Z (please print)
W " ��
Signature Title 1- I 1�^�- ,
(over)
DOH-1555(02/2004)