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Bancroft, Naomi E. /33 -7 • NEW YORK STATE DEPARTMENT OF H EALTH • Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Naomi E Bancroft Female Date of Death Age If Veteran of U.S.Armed Forces, 12/20/2020 75 Years War or Dates F,. Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing WManner of Death ©Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined Pending V Circumstances Investigation W Medical Certifier Name Title Roslyn Socolof MD Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 228 ▪Burial Date Cemetery,Crematory or Facility Name 12/22/2020 Pine View Crematory ❑Entombment Address 0 Cremation Queensbury Town,New York ❑Donation ElRemoval Date Place Removed and/or and/or Held pHold Address 0 a Date Point of 0 ❑Transportation Shipment $ by Common Carrier Destination ElDisinterment 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 (— Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/22/2020 Registrar of Vital Statistics Carofinefclegarre Barber(E(ectronical(y Signed) (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: Date of Disposition f 2—23 1ad Place of Disposition F— vILI 2 (address) W Cr (section) (lot number) (grave number) 8 Name of Sexton or Person i ha of Premises u 1� -r (J £ JL � % (please print) i7 W Signature Title ��/>✓ :t�p yeye'i;fie, DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2b) 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#