Curtis, Wava 11
NEW YORK STATE DEPARTMENT OF HEALTH ' 31(1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wava Curtis Female
Date of Death Age If Veteran of U.S.Armed Forces,
July 14, 2013 82 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address GlensFalls Hospital
p Manner of Death 0 Natural Cause El Accident fl Homicide Ei Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Michael Lieberth
Address
17 Baywood Dr,Queeensbury,NY 12804
Death Certificate Filed District Numbe5601 Register uP
City, Town or Village Glens Falls ````
❑Burial Date Cemetery or Crematory
❑Entombment July 16,2013 Pine View Crematory
Address
®Cremation Quaker Road, Queeensbury,NY 12804
Date Place Removed
ZG ni Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
e5 El Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
W
Permission is her by ranted to dispose of the humarLemains d cribedbove as indi ated.
Date Issued OC? Registrar of Vital Statistics �.
G��'1-64/1( . nat re)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
alDate of Disposition 1'1(^(3 Place of Disposition
W (address)
cn
(section) t number) (grave number)
Z Name of Sexton or Person in Charge of Premises �,`�t.a
(pleasernt)
W Signature /� Title ('
acitTAL
(over)
DOH-1555(02/2004)