Cornell, Patricia 3
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia L. Cornell Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 15, 2013 81 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Wp Manner of Death in Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
al• Medical Certifier Name Title
Q Suzanne Rayeski,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Regii er Number
City, Town or Village Glens Falls,NY 5601 w ]la
❑Burial Date Cemetery or Crematory
December 18, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
Cl)
O Date Point of
NTransportation 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
I- Remains are Shipped, If Other than Above
a Address
L
W
a, Permission is hereby granted to dispose of the human remains described above as indicated.
1
I
Date Issued i Z f i 7 l i 3 Registrar of Vital Statistics L/l)c.c.itstv u lA)
(sign
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition iz'ke,-13 Place of Disposition . tjt,,J 6-okif
2 (address)
W
CO
CL (section) r�(lot number)r (grave number)
QName of Sexton or Person in Charge of Premises ,r JPN �
Z (pl ase print)
W App(„ 2Title Cl2iOWN-
Signature f
(over)
DOH-1555(02/2004)