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Koke, Thea Albertha NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Thea Albertha Koke Female Date of Death Age If Veteran of U.S.Armed Forces, 07/07/2021 88 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 53 Cascade Court,Queensbury Town,New York 12804 p Manner of Death ©Natural Cause El Accident Homicide El Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title CI Eileen Spinelli NP Address Carey Rd,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 142 ©Burial Date Cemetery,Crematory or Facility Name 07/17/2021 Pine View Cemetery Entombment Address ❑Cremation Queensbury,New York ElDonation ZO ❑Removal Date Place Removed and/or and/or Held - Hold Address 0 Date Point of N ❑Transportation Shipment p by Common 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 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/09/2021 Registrar of Vital Statistics Caroline xfdegarde Barber(Electronically 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: WDate of Disposition ' . 17 .2021 Place of Disposition 21 Quaker Rd. Queensbury, NY 12804 2 (address) W Seneca 1 -C 2 CC (section) (lot number) (grave number) S Name of Sexton Person in Charge of Premises Connie Goedert (please print) W Signature due. " Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 012864 Receipt Human remains of `7 V fi _ 1. delivered on , 20 ievd Cemetery Representing the funeral home named on • 't Official Funeral Directors Reg.or License# KOKE NAME Thea Albertha Koke Age: 88 Lot Owner: John & Theodora Koke Lot# Seneca 1 C Grave# 2 Case: Concrete Died: 7/7/2 0 21 Interred: 7/1 7/2 0 21 Funeral Home: Regan Denny Stafford Cemetery: Pine View