Kapetsonis, Effrossini NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ef rossini N. Kapetsonis Female
Date of Death Age If Veteran of U.S. Armed Forces,
4/7/2018 91 War or Dates NA
F Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls,NY Street Address 57 Broad St.,Glens Falls,NY
W Manner of Death E Natural Cause Accident E Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
W Medical Certifier Name Title
0 William A.Tedesco MD
Address
3 Iron gate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 1 S
O
®Burial Date Cemetery or Crematory
April 13, 2018 Pine View Cemetery
El Entombment Address
❑Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F' Hold
N
p Date Point of
N E Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
(i Renterment 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
4 Name of Funeral Firm Making Disposition or to Whom
h-; Remains are Shipped, If Other than Above
Address
W'
13. Permission is herby,granted to dispose of the human r€nains de cribed abo e as indi ted
Date Issued 0 1 fit)/, Registrar of Vital Statistics
(signature)
District Number 57, 7 Place l - -4 >71
I certify that the remains of the decedent identified above were isposed of in accordancs permit on:
iti z ay (2o
Date of Disposition 41 (3 I �� Place of Disposition � i
2 4474 r address)
w roil 28-b I
�' tion) (lot number) (grave number)
0 Name of ton or Person in Charge of Premises /J&)t6 ,,
Z (ple trilA.70W Signature�� % ' ' 1 / 1,i Titl42 -4
(over)
DOH-1555(02/2004)