Van Diest, Anna Maria CLF
HNEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Anna Maria Van Diest Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/04/2022 82 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 15 Arbor Drive,Glens Falls,New York 12801
0 Manner of Death p Natural Cause ❑Accident 0 Homicide OSuicide Undetermined ❑Pending
ILI
Circumstances Investigation
W Medical Certifier Name Title
G Robert Love MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed city Of Glens Falls District Number Register Number
,Town or Vi ll5e C' e 5601 302
Burial Date Cemetery,Crematory or Facility Name View
0 Address
Cremation Queensbury Town,New York
Donation
Removal Date Place Removed
and/or and/or Held
NHold Address
0
d Date Point of
(I) Transportation
5 by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
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
IH Remains are Shipped,If Other than Above
S Address
IC
IW
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/06/2022 Registrar of Vital Statistics Sifigan.W°Cin(fEkamatcally,SO4
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition le ll In Place of Disposition .f
W (address)
W
N (section) fLot number) c. a (grave number)
� Ir
8 Name of Sexton or Person in Charge of Premises Aiivtl._ .4ZCe
ase print) , y
W Pfe
Signature Title ' ' ff
DOH 1555(07/18)p 1 of 2
�. :)157 6 7
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#