Juliano, Judith It 3c
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Judith E. Juliano Female
Date of Death Age If Veteran of U.S. Armed Forces,
ri, January 20, 2013 59 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
44 Manner of Death 0 Natural Cause 0 Accident 0 Homicide n Suicide 0 Undetermined ri Pending
14 Circumstances Investigation
Medical Certifier Name Title
John P. Stoutenburg,MD
Address
102 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Numbe5601 Register Number
City, Town or Village Glens Falls cS�0I 0.1',5
❑Burial Date Cemetery or Crematory
ID Entombment January 22,2013 Pine View Cremation
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
and/or Address
E Hold
U)
O Date Point of
N0 Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
Permission is hereby granted to dispose of the huma emai described above as ndica -d.
Date Issued Registrar of Vital Statistics 4‘. 0
(signature)
District Number 5601 Place Glens Falls /'ter /age/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LaDate of Disposition 1-22-I3 Place of Disposition 4?, LJ 41 Creetti NI.-
W (address)
U)
p0 (section) Not numb5r) (grave number)
Name of Sexton or Person in Char a of Premises r)ai P 0"ait
Z Yplease print)
W t
Signature L. Title OM wr y
(over)
DOH-1555(02/2004)