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Shafer, Judith 02-3 NEW YORK STATE DEPARTMENT OF aIEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Judith A. Shafer Female Date of Death Age If Veteran of U.S. Armed Forces, .: November 25, 2012 73 War or Dates i17 of Death Hospital, Institution or iTown or Village 44 '/i/i Street Address Glens Falls Hospital b Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending .W, Circumstances Investigation us Medical Certifier Name Title 41 John Stoutenberger,MD Address 102 Park Place,Glens Falls,NY Mh Certificate Filed ' District Number Register Num er Town or Village Glens Falls 5601 ..."144 ❑Burial Date Cemetery or Crematory November 28, 2012 Pine View Crematorium ❑Entombment Address ❑X Cremation 21Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address F" Hold N , 0 Date Point of WTransportation 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 14,4 Remains are Shipped, If Other than Above "5 Address le l E Permission is hereby granted to dispose of the human emains escribed a ve as in.' •. Date Issued Registrar of Vital Statistics ©' �J-r ur (signature District Number 5601 Place Glens Falls /A/ /02(9)/ ▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition H/261 it Place of Disposition .epokaa rio._.. 2 (address) W Cl) 0 (section) 41(1)17L / (lot numbertti (grave number) Q Name of Sexton or Person in Charge of Premises �-r Z (please print) W Signature Title C1.11-c(g. (over) DOH-1555(02/2004)