Stanford, Carol # Sri
NEW YORK STATE DEPARTMENT OF HEALTH% "'' •
Vital Records Section Burial - Transit Permit
Name First Middle Las Sex
Carol L Stanford Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/31/2012 59 years War or Dates
Place of Death Hospital, Institution or
Ca9P0Swn or ViMalg6XX Greenfield Street Address 370 Daniels Road, Lot 20
til
Manner of Death❑Natural Cause 0 Accident 0 Wbmicide El Suicide ri❑Undetermined Pending
1 Circumstances Investigation
ut Medical Certifier Name Title
44 John Demartino Coroner
Address
339 Northline Road, Ballston Spa, N Y 12020
Death Certificate Filed District Number Register Number
CiWwn or ViMX Greenfield 4557 28
>>❑Burial Date Cemetery or Crematory
11/02/2012 Pineview
ii.i:i 0 Entombment Address
0 remation. Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
44 and/or Address
i= Hold
SA
{? Date Point of
liEl Transportation 1 Shipment .
C by Common Destination
Carrier •
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registt ti 4ri Number
Name of Funeral Home Densmore Funeral Home
iiin Address
7 Sherman Avenue, Corinth, New York 12822
Ilil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
t Address
#i
f
t3 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/02/2012 Registrar of Vital Statistic$
(signature)
District Number 4557 Place Greenfield
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ui p !I /Lti2 DispositionQ l r tr4 Date of Disposition Place of ,K ,/� orw..—
(address)
Ui
fil
CC (section) /� (lot number), (grave number)
CI Name of Sexton or Person in Charge f Premises (((' (a c7 -S r i 14
r /114 (please print)
Signature Title <ate tv lee
(over)
DOH-1555 (02/2004)