Covals, Ilse f i # /1/2
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ilse Covals Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 26,2013 85 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 93 Rockhurst Rd
pManner of Death a Natural Cause �Accident 0 Homicide 0 Suicide Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
Michael Fuller rte
Address
48 East Street,Fort Edward,NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 ' E(5
❑Burial Date Cemetery or Crematory
❑Entombment October 28,2013 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
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
H Remains are Shipped, If Other than Above
2 Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )(:)i75414013 Registrar of Vital Statistics G c CM
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
wDate of Disposition (0 /NI13 Place of Disposition , 6,4or,•'s
W (address)
(section) (lot rnumber) (� (grave number)
p Name of Sexton or Person in,Charge of Premises (���y .._ towytt
Z (plbbase print)
W Signature Title 0111-m/iNe_
(over)
DOH-1555(02/2004)