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O,Connell, Patricia D 4- 13©0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Patricia D O'Connell Female Date of Death Age If Veteran of U.S.Armed Forces, 12/10/2020 73 Years War or Dates �,. Place of Death Hospital,Institution or W City,Town or Village Queensbury Town Street Address 70 Needlepark Circle Apt 3,Queensbury Town,New York 12804 Manner of Death Natural Cause 0 Accident ❑Homicide ❑Suicide I=1 Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Christopher Mason DO Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 225 ❑Burial Date Cemetery,Crematory or Facility Name 12/12/2020 Pine View Crematory ❑Entombment Address ElCremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held i—usHold Address O Date Point of co ❑Transportation Shipment p by Common Carrier Destination ❑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 Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address CC iW O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/11/2020 Registrar of Vital Statistics Caroli'neJlildegarcle Barber(EfectronicallySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i— f� W Date of Disposition IZ frj jQ Place of Disposition Zit Utz &At( 2 (address) IW CC CC (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises � - 1"— `�"^t Z (/ease print) W Title (n Tv( Signature DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014 2 9 0 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#