Morrison, Valerie r NO§ # /3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Valerie
M. Morrison Female
Wi.> Date of Death Age If Veteran of U.S. Armed Forces,
April 22,2013 52 War or Dates
V.';
. Place of Death P
Hos ital, Institution or
City, Town or Village Granville Street Address Orchard Nursing& Rehab Center
Title
Manner of Death X Natural Cause n Accident in Homicide Suicide n i Undetermined l Pending
Circumstances Investigati' on
�s '
Medical Certifier Name
Sean Kimball,MD
Address
r - 79 North Street,Granville,NY 12832
Death Certificate Filed District Number Register Number
City, Town or Village Granville Granville 5156 I
❑Burial Date Cemetery or Crematory
April 25, 2013 Pine View Cremation
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
ri Transportation Shipment
p by Common Destination
_ Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
f 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 p i(I P519013 Registrar of Vital Statistics Yt ia)-) ati
(sig lure)
.: District Number s 7S Place Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
tit Date of Disposition i i %3 Place of Disposition
'(�.Q �tw �romc(yc���
W (address)
cc (section) di
(lot number) (grave number)
cp Name of Sexton or Perso in Charge o Premises tt
Z (please print)
W Signature Title Cr o1
(over)
DOH-1555(02/2004)