Virta, Michelle 51/
NEW YORK STATE DEPARTMENT OF HEALTH '- 4
ff
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michelle Ann Virta Female
y Date of Death Age If Veteran of U.S. Armed Forces,
February 17, 2013 50 War or Dates
�. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
W: Manner of Death ❑X Natural Cause U Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
tY
vi Medical Certifier Name Title
P• aul J.Byron,MD
Address
200 Smith Drive,Corinth,NY 12828
'` Death Certificate Filed District Number Register Number
;:' C• ity, Town or Village Glens Falls 5601 Ej q
❑Burial Date Cemetery or Crematory
February 20, 2013 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment 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
I Remains are Shipped, If Other than Above
Address
1
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/ t 9 j /3 Registrar of Vital Statistics C'L 'JW_.1/4--C)
{,,. (signature)
{,,,
%:% District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-2)-t3 Place of Disposition to C/iw.�irv,•.,
2 (address)
W
CO
Ce (section) 4 (lot nur ) (grave number)
pName of Sexton or Person in Charge of Premises t �l
ZAFL_ _..A. -- (please print)
W Title CUM Signature
(over)
DOH-1555(02/2004)