Whitman, Karen NEW YORK STATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Karen L. Whitman Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 2, 2013 61 War or Dates
i,.. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 260 Aviation Road
Manner of Death n Natural Cause 1-1Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
U.
Medical Certifier Name Title
�; Dr.William Parker
Address
{% 100 Broad Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 /
❑Burial Date Cemetery or Crematory
❑Entombment Pine View Crematory
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ• ❑Removal and/or Held
and/or Address
H Hold
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Q Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
'1.:- 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
iRemains are Shipped, If Other than Above
Address
14
at
Permission is hereby granted to dispose of the human r ains described above a ndicated.
Date Issued /-7...a-d3 Registrar of Vital Statistics OCI,-* _ A
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
W Date of Disposition -/3 Place of Disposition We., 14,E Okilv1(71-01(1/
2 (address)
W
N
O (section) (lot']umber) (grave number)
QName of Sexton o Charge of Premises �� w�/r 't�
�Z (please print
Signature /►7 ct Title eder/(,A4e,tZ a>5
(over)
DOH-1555(02/2004)