Mitchell, Kathy E g3
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Kathy E.Mitchell Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/08/2021 68 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death a Natural Cause El Accident 1=1 Homicide ❑Suicide Undetermined Pending
VCircumstances Investigation
GMedical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601
ElBurial Date Cemetery,Crematory or Facility Name
06/10/2021 Pine View Crematory
Entombment Address
ICremation Queensbury Town,New York
❑Donation
0 ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
CL Date Point of
Cl) ❑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
"g Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/10/2021 Registrar of Vital Statistics RD6ertfIrulraw Curtis gkctroncallySrgnts
(signature)
District Number 5601 Place Glens Falls, 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 C III]71 Place of Disposition 4d L pt
2 (address)
W
CC N
(section) J (lot number) (grave number)
0 Name of Sexton or Person in Charge of Pr ises
Z (plea st.print)
W Signature Title l�r%^W 1271'�
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 0 I
1, rs� jU
Receipt
Human remains of's delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#