Bachman, Jane NEW YORK STATE DEPARTMENT OF HEALTH 4 . I
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
. Jane Anne Bachman Female
fa; Date of Death Age If Veteran of U.S. Armed Forces,
e,,, September 30,2013 58 War or Dates
Place of Death Hospital, Institution or
. City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause n Accident n Homicide 0 Suicide n Undetermined n Pending
Circumstances Investigation
, Medical Certifier Name Title
:„ Frances Bollinger,MD
Address
.:, Glens Falls,NY
{„
Death Certificate Filed District Number Re ister Number/ /
-' City, Town or Village
fir:; Y. 9 Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment October 7, 2013 Pine View Crematorium
Address
E1 Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
O �Removal and/or Held
and/or Address
E Hold
Cl)
0 Date Point of
u) n Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
❑Reinterment ' Date Cemetery Address
w Permit Issued to
Wes, 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
Remains are Ship
ped, If Other than Above
I
Address
40
Permission is hereby granted to dispose of the human remains descri d a ov s i c ted.
iG kye "
Date Issued /Or/�10/� Registrar of Vital Statistics
. (signature)
District Number 5601 Place Glens Falls,NY
rn
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition lo)%/0 Place of Disposition AdJuy ack...
Ill (address)
0 (section) pot number) r (grave number)
p Name of Sexton or Person in Charge o Premises g,)kn„itir
WZ (pteseprint)
Signature ',at--
I - Title efZIVAY{fd
(over)
DOH-1555(02/2004)