Gifford, Jane A • 7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jane A.Gifford Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/17/2021 69 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 38 Meadowview Road,Queensbury Town,New York 12804
'p Manner of Death ❑X Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Mark Quaresima MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 107
ElBurial Date Cemetery,Crematory or Facility Name
05/19/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
ElDonation
0 Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
�
U) 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
Remains are Shipped,If Other than Above
2 Address
CC
ILLI
11.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/19/2021 Registrar of Vital Statistics Carolinex!legara Bather( ctrntrically5rgrred)
(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:
W Date of Disposition si Z( I Zia Place of Disposition t,,,, L
(address)
W
CC (section) (lot number) (grave number)
O• Name of Sexton or Person in Charge of Prem. s
(p/e a print) /
• Signature Title ` �
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) y 1 4 8 n
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#