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LaSelva, Barbara Lynn NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Barbara Lynn LaSelva Female Date of Death Age If Veteran of U.S.Armed Forces, 11/19/2021 75 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital 1p Manner of Death ©Natural Cause 1=1 Accident ❑Homicide Suicide ❑Undetermined 11 Pending Circumstances Investigation WMedical Certifier Name Title O Emily Rapasadi PA Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 526 ❑Burial Date Cemetery,Crematory or Facility Name 11/23/2021 Pine View Crematory ❑Entombment Address ElCremation Queensbury,New York ❑Donation Z Removal Date Place Removed and/or and/or Held N Hold Address 0 O. Date Point of to ❑Transportation Shipment S 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 5 Address W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/22/2021 Registrar of Vital Statistics T g6ertAndrew Curtis(ECectronica1Ty Signed) (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: z �u (k W Date of Disposition f��2+��Z� Place of Disposition ^� L 2 (address) W (section) (lot number) (grave number) SName of Sexton or Person in Char of Premises t`1 L— ICI Z `. � (pi se print) Wnature Title (*Go g Si OWL DOH-1555(07/18)p 1 of 2 Ii ♦i ("' oN iY Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#