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Waite, Diane J.
NEW YORK STATE DEPARTMENT OF HEALTH I1I kt Bureau of Vital Records t.' Burial - Transit Permit Name First Middle Last Sex Diane J.Waite Female Date of Death Age If Veteran of U.S.Armed Forces, 11/15/2020 60 Years War or Dates F. Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 4080 Rockwell Street, Hadley Town, New York 12835 Manner of Death ©Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending IJJ 0 Circumstances Investigation ILI Medical Certifier Name Title O Lisa Greenwald NP Address 2 Irongate Plaza,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Hadley 4558 15 ❑Burial Date Cemetery,Crematory or Facility Name 11/17/2020 Pine View Crematory Entombment Address ElCremation Queensbury Town,New York ❑Donation o ElRemoval Date Place Removed and/or and/or Held - Hold Address N 0 a Date Point of t/) ❑Transportation CI Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500,Lake Luzerne,New York 12846 Name of Funeral Firm Making Disposition or to Whom I. Remains are Shipped,If Other than Above 2 Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/16/2020 Registrar of Vital Statistics Pauline G Smead(Electronically Signed) (signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permi F- Z Date of Disposition I1 I Ig1' Place of Disposition ., Zitop____ W (address) W Er N (section) (lot number) (grave number) O Ch ra}•Pt.., PM t cl l t O Name of Sexton or Person in Charge of Pre ises k Z (p ase print) J W Signature � Title �Ind DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) W,Jt_ ``` (J1.4 2 0 6 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#