Lanphere, Gertrude NEW�RK STATE DEPARTMENT OF HEALTH
' a Records Section Burial - Transit Permit
Name First Middle Last Sex
Gertrude _ M. Lan here female
Date (if Death Age If Veteran of U.S. Armed Forces,
March 28 1998 91 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village City of Glens Falls Street Address Eden park Nursing Home
Manner of Death ❑Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined El Pending
--- e - __
Circumstances Investigation
: Medical Certifier Name Title
Robert Evans MD
Address
3 Iron ate Center Glens Falls NY 12801
Death Certificate Filed District Number Register, u er
nb.
City, Town or Village City of Gle Fal s
Date Cemetery or Crematory
ElBurial March 31, 1998 Pine View Crematory
Address
I❑Cremation Queensbury,, New York
Date Place Removed
❑Removal
Z
0 and/or Address and/or Held
Hold
O Date Point of
❑Transportation Shipment
fl by Common Destination ---
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
>. Name of Funeral Home Regan and DennyFuneral Service 01565
Address
53 Quaker Road, Queensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain escri ed bo as indicated.
Date Issued 3o Registrar of Vital Statistics
(signature)
District Number Place �14O?r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition .? `3/' Place of Disposition�j�/1/,�Z��4) if f/VA17
(address)
W (section) -t,nrumMz
(grave number)
GName of Sexto or Perso in Charge o Premises , 'mil J[ � . , / / 1
F (please print) r
Signature Title 4— ,6w ef SSl
DOH-1555 (10/89) p. 1 of 2 VS-61