Copeland, Marjorie o * "rT .7111 U
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marjorie J Copeland Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/08/2013 89 years War or Dates
F-' P --_ of Death Hospital, Institution or
owner II XX Glens Falls Street Address park st glens falls n y
o U�.nner of Death N tural Cause El Accident El Homicide El Suicide 0-Undetermined ❑Pending
ii Circumstances Investigation
tu Medical Certifier Name Title
0 Gamal Garhy Khaliftu M f)
Address
100 Park Street Glens Falls, N Y
math Certificate Filed District Number Register Number
Ci Towry1)lIXj(XX Glens Falls 5601 520
❑Burial Date Cemetery or Crematory
❑Entombment 12/09/2013 Pineview Crematory
Address
. Cciamation Queensbury, N Y 12804
Date Place Removed
2 ❑Removal and/or Held
2 and/or Address
F- Hold
U)
0 Date Point of
itt❑Transportation Shipment
ES by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tr
tl
` Permission is hereby granted to dispose of the human r ains described ab e as Indic- ed.
Date Issued 12/09/2013 Registrar of Vital Statistics .-,off, G�
(signature)
District Number 5601 Place 7.W I
-'' I certify that the remains of the decedent identified above were isposed of in accordance with this permit on:
ILI Date of Disposition ia-lo-t3 Place of Disposition gadit,,) ( or, ,,,
(address)
Ili
CC (section) (lot number)c (grave number)
• Name of Sexton or Person - Charge f Premises di-11.-- V/11.4
11-
Z lease print)
LO Signature Title C t1AT
(over)
DOH-1555 (02/2004)