Merrill, Barbara M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Barbara M.Merrill Female
Date of Death Age If Veteran of U.S.Armed Forces,
08/17/2021 76 Years War or Dates
Place of Death Hospital,Institution or
2
1/1City,Town or Village Glens Falls Street Address Glens Falls Hospital
a Manner of Death ❑X Natural Cause El Accident 0 Homicide ❑Suicide ❑Undetermined El Pending
W U Circumstances Investigation
W Medical Certifier Name Title
a Marvin Davidowitz MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 354
❑Burial Date Cemetery,Crematory or Facility Name
08/24/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Z ❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
N
0
a. Date Point of
u) ❑Transportation Shipment
G 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
t Remains are Shipped,If Other than Above
a Address
Ce
Ui
Q' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/24/2021 Registrar of Vital Statistics P6en,?n"rewCurt c(Ekctronca/6,5 nea)
(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
onn:,�!
I—
Z Date of Disposition ��2•) Place of DispositionIIJ ,1
r> .t) 4 (A.) GrOvi'�R"'I
2 (address)
W
cc (section) (lot number) (grave number)
8 Name of Sexton or Person in Charge of Premises j'Jfh"U S� /;f
Z (please print)
W Signature ' J Title Cfc,A6/1(
DOH-1555( p t of 2
38
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral.bane-named on burial permit-
Official Funeral Directors Reg.or License#