Dugan, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne M. Dugan Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 6, 2013 / f War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident El Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Dunsuhan Sooriabalan
Address
9 Carey Rd,Queensbury,NY 12804
Death Certificate Filed Glens Falls District Number Register Number
City, Town or Village 5601 c.�' 7
❑Burial Date Cemetery or Crematory
0 Entombment Address
❑Cremation
Date Place Removed
ZZ Removal and/or Held
and/or Address
Hold
N
0 Date Point of
51/2 ❑Transportation Shipment
p by Common Destination
Carrier
Ei
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
I— Remains are Shipped, If Other than Above
gAddress
Permission is hereby granted to dispose of the human remains�j � described above as indicated.
Date Issued k219 / /3 Registrar of Vital Statistics W)C,:..I4y..Q
(signature)
District Number 5601 Place Glens Falls it/Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 1, •II-13 Place of Disposition t',r,U&w on _
(address)
cn
CG
0 (section) (lot`number)r (grave number)
el Name of Sexton or Person in Charge of Premises /14* b, 31 r'iff
(blase print)
Signature Title CQMj};r/II/�
(over)
DOH-1555(02/2004)