Choukeir, Patricia Ann (17r) 4zc
NEW YORK STATE DEPARTMENT OF H EALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Patricia Ann Choukeir Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/31/2022 57 Years War or Dates
t— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑Accident El Homicide ❑Suicide Undetermined ❑Pending
iW Circumstances Investigation
W Medical Certifier Name Title
t7 Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
Cit ,Town or Villa,g 5601 193
Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
ORemoval Date Place Removed
p and/or and/or Held
N Hold Address
CO❑Transportation Date Point of
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
ElReinterment
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
I— Remains are Shipped,If Other than Above
2 Address
Q
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/04/2022 Registrar of Vital Statistics Alvan.Wo/n(EGctmnic S(gned)
(signature/
District Number 5801 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition LI/il I2z Place of Disposition `I s. at- � ..._r, . •
2 (a dress)
IL
N (section) (lot number (grave number)
CC - '2 Name of Sexton or Person in Charge of Premises t ts3tTi..- *IA/
yplease print
ir
W4.2 1 l�RE 1)1 One.
Signature G..� Title
DOH 1555(07/18)p t of 2
� , 5 crZ at
Public Health Law Sec. 4145(2b)
Receipt
Human remains of k delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#