Scanlon, Grace _,, 511,
NEW YORK STATE DEPARTMENT OF HEALTH` Burial _ Transit Permit
Vital Records Section �.
• Name First Middle Last Sex
Grace E. Scanlon Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 25, 2013 93 War or Dates
t,,,• Place of Death Hospital, Institution or
Z' City, Town or Village Bolton Street Address 113 Norwood Drive
3 Manner of Death X Natural Cause n Accident pi Homicide n Suicide Undetermined Pending
Itt Circumstances Investigation
ut Medical Certifier Name Title
B• ryan Smeed MD
Address
• D• eath Certificate Filed District Number Register Number
f,i City, Town or Village Bolton Landing Bolton Landing5f'o N. /D
❑Burial Date Cemetery or Crematory
May 28, 2013 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
H Hold
U)
O Date Point of
NU Transportation 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
A Permission is hhereby,granted to dispose of the human ai described a e as indicate .
Date Issued c��/07AR Registrar of Vital Statistics
A ePtZ rz( Gl e)!1 /C__
District Number Bolton LanditiOCe Bolton Landing
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition S(3043 Place of Disposition 4?vt)L.... Comityrv4,
2 (address)
W
N
re (section) (I t number) (grave number)
O• Name of Sexton or Person ' Charge of Premises 4,)1 ,,,c�h,(�
IT
lease print)
W L �_ Title Cei€M
Signature
(over)
DOH-1555(02/2004)