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Bannon, Diane h cic NEW YORK STATE DEPARTMENT OF H EALTH _ Burial- Transit Permit Bureau of Vital Records Name First Middle Last Sex Diane Bannon Female Date of Death Age If Veteran of U.S.Armed Forces, 06/19/2021 58 Years War or Dates Place of Death Hospital,Institution or Z- City,Town or Village Northumberland Town Street Address 71 Homestead Road,Northumberland Town,New York 12866 0 Manner of Death ©Natural Cause El Accident ❑Homicide El Suicide 11 Undetermined El Pending 0 Circumstances Investigation W Medical Certifier Name Title 0 John Pezzulo DO Address 211 Church St,Saratoga Springs,New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Northumberland Town 4563 8 ❑Burial Date Cemetery,Crematory or Facility Name 06/23/2021 Pine View Crematory 0 Entombment Address f]Cremation Queensbury,New York 0 Donation Z 0 Removal Date Place Removed and/or and/or Held H Hold Address N 0 Date Point of fb ❑Transportation Shipment S by Common Carrier Destination 11 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 f W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/21/2021 Registrar of Vital Statistics Dense D Murphy(ECectronicalTy Signed) (signature) District Number 4563 Place Northumberland Town, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: � WDate of Disposition (o t3�tiI Place of Disposition (address)...L 40.--- W N (section) ^(lot number) - (grave number) Ir 8 Name of Sexton or Person in Charge of P ises t � ` Al z ase print) W Signature Title c �'� (�� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 014381 Receipt Human remains of delivered on , 20 J i Pine View Cemetery Representing,the funeral home named on burial permit Official Funeral Directors Reg.or License#