McLaughlin, Janice NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
:< Date of Death Age If Veteran of U.S. Armed Forces,
11 16 98 71 War or Dates NO
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death a Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Evans MD
Address
3 Iron ate Glens FAlls NY 12801 Re ter Number
Death Certificate Filed District Number g
City, Town or Village Glens Falls 5601
Date Cemetery or Crematory
El Burial 11/17/98 Pine View Crematorium
Address
>. ®Cremation Quaker Rd. Queensbury,NY
Date Place Removed
Z❑Removal —7and/or Held
.. and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment
Date Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
<' Name of Funeral Home Singleton Healy 01773
Address
407 Bay Rd. Queensbury,NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:< e of the human remains des ri
Permission is hereby granted to dispos b d abov s i c d.
Date Issued 11/17/98 Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls,NY
JOName
certify that the remains of the decedent identified above were disposed of in accordance with this- permit on:
/ f l lam'
ate of Disposition � Place of Disposition /1flo�' /t(address)
ction) (lot n ber) �1, ) (grave number)
of Sexton or Person in Charge of Premises /��L �D TIC,/-&`l �— (please print)ignature `�- Title
DOH-1555 (10/89) p. 1 of 2 VS-61