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Lopez, Anthony /L) 41 2in i IS, NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Anthony Lopez Male Date of Death Age If Veteran of U.S.Armed Forces, 03/07/2024 95 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Glens Falls Center for Rehabilitation and Nursing p Manner of Death ❑X Natural Cause IllAccident1:1 Homicide Suicide FlUndetermined Pending W Circumstances Investigation W Medical Certifier Name Title 0 Mikram Jafri MD Address 152 Sherman Ave,Queensbury Town,New York 12801 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 40 Burial Date Cemetery,Crematory or Facility Name 03/11/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation Removal Date Place Removed and/or and/or Held F Hold Address N 0 Date Point of N❑Transportation Shipment p by Common 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 F— Remains are Shipped,If Other than Above a Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/11/2024 Registrar of Vital Statistics Caroline Jfifeegarde Barber(ECectronicaCCy Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 3111 Ill Place of Disposition l'R-ud es (�0 /1•r'wfN 14---- W CC (section) (lot number) (grave number) CC G Name of Sexton or Person in Charge of Premises AA 4e riot/ , it z / lid^ W Signature Title DOH-1555(o7/1S)p 1 of 2 ' A P t 1 Public Health Law Sec. 4145(2b) Receipt 1 Human remains of delivered on , 20 1 1 1 Pine View Cemetery Representing the funeral home named on burial permit 1 Official Funeral Directors Reg.or License#