Seaman, Helen Rose NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Helen Rose Seaman Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/21/2021 97 Years War or Dates
1_, Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 15 Needle Park Circle 2,Queensbury Town,New York 12804
`p Manner of Death 0 Natural Cause 0 Accident ElHomicide ❑Suicide ❑Undetermined El Pending
V Circumstances Investigation
GMedical Certifier Name Title
Sharon Shannon NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 24
0 Burial Date Cemetery,Crematory or Facility Name
01/22/2021 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
0ZRemoval Date Place Removed
and/or and/or Held
usHold Address
0
d 1-1 Date Point of
(A ❑Transportation
p by Common Shipment
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
1- Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/22/2021 Registrar of Vital Statistics Carolnexkiegard Bar6ergkctronicall: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:
Z
W Date of Disposition 1/Za 1Zt Place of Disposition 1 '
2 �(address)
W
CC N (section) /tot number/ (grave number)
gName of Sexton or Person in Charge of P emises //,t"< 1. )Y�A.4,�}
Z (ptedl*print/ --���
W Signature ,t:--S Title 1174r"'�'f"1 vt!
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
w 1.4.o 2
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#