Zerbst, Louise Helen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ""
Name First Middle Last Sex
Louise Helen Zerbst Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/10/2022 74 Years War or Dates
H Place of Deattf Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
p Manner of Death 0 Natural Cause IllAccident Homicide OSuicide FlUndetermined El Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 467
EdBurial Date Cemetery,Crematory or Facility Name
09/14/2022 ,,, Pine View Crematory
Entombment Address
(Cremation Queensbury,.NewYork
DDonation
ZO❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0
0. Date Point of
CD❑Transportation Shipment
p by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
0 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
H Remains are Shipped,If Other than Above
a Address
Q
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/14/2022 Registrar of Vital Statistics Megan NoLin(ECectronica1Ty Signed)
(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:
I— ;�
Z Date of Disposition q I/S]22 Place of Disposition .I'�,..
LIJ
2 /address/
W
NCC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of emises '" r,t4f-- SNA,4 ti
l ase print) �^
W Title G R F m#��((
Signature
DOH-1555(o7/18)p 1 of 2
i
Public Health Law Sec. 4145(2b) "'
Receipt
i
y Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#