Salzman, Lefa t 1 r
NEW YORK STATE DEPARTMENT OF HEALTH `�
Vital Records Section Burial - Transit Permit
s% Name First Middle Last Sex
Lefa Salzman Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 21,2013 91 War or Dates _
''; Medical Certifier Place of Death Hospital, Institution or
City, Town or Village Granville Street Address Indian River Nursing Home1
Manner of Death
Natural Cause Accident Homicide �]Suicide Undetermined Pending
Circumstances Investigation
Name Title
N P
�./4 pe r-rr
Address
l; /7 /Pd<SC'� k
,:
Death Certificate ile District u/j t1 Number Register
::'
';: City, Town or Village Granville,
NY
❑Burial Date Cemetery or Crematory
September 25,2013 Pine View Crematorium
❑Entombment Address
El Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 0 Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N 0 Transportation Shipment
p by Common Destination
Carrier
D
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
a 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
1'`, Remains are Shipped, If Other than Above
Address
/-, Permission is he eby ranted to dispose of the human remains escribe• •ove indicated.
A Date Issued g a o�Q/3 Registrar of Vital Statistics
(signature)
District Number 5-pc Place Granville,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LUDate of Disposition ►IZ6f j3 Place of Disposition gelU / (Oaf,it......
W (address)
CO
a_ (section) A
t number) (grave number)
p Name of Sexton or Person in arge of Premises );-hO s-3/h4}
Z (please riot)
ILSignature L Title ellelt09IL
(over)
DOH-1555(02/2004)