Stiles, Emily NW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Emily M Stiles F'mAle
Date of Death Age If Veteran of U.S. Armed Forces,
05/02/2006 94 years War or Dates
Place of Death Hospital, Institution or
City, Town dfX(X gNXXXX City Of Glens Falls Street Address Glens Falls Hospital
0 Manner of Death I.L9 Natural Cause ❑Accident 0 Homicide 0 Suicide Undetermined Pending
itaCircumstances Investigation
ut Medical Certifier Name Title
fl. Sean Bain M D
Address
Glens Falls Hospital, Glens Falls, N Y
Death Certificate Filed District Number Register Number
City, Town N Ii XXXX City Of Glens Falls 5601 201
[lYurial Date Cemetery or Crematory
05/05/2006 Pine View Cemetery
;i ❑Entombment Address
:i❑Cremation Queensbury, NY 12804
Date Place Removed
Z�Removal and/or Held
.� and/or Address
t= Hold
U)
Date Point of
lik Q Transportation Shipment
ea by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01181
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
Cr
Ui
P" Permission is hereby granted to dispose of the human remains described above as indicated,
Date Issued 05/04/2006 Registrar of Vital Statistics R6 , 'A-(,t, 3 / i
(signature)
District Number . {j Q ) Place C J . n S CA I 1 S / N r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
iii Date of Disposition 5/5/06 Place of Disposition P I VE VI EW CEME IERY,0IJEENSSUR'( Nv
2 (address)
tai
to MoHANK 129, 130 2
ce (section) (lot number) (grave number)
Q
ti Name of Sexton or Person in Charge of Premises ;1 ;)-lAE:_ GEN I ER
z... (please print)
Signatures 91Title SUP r
(over)
DOH-1555 (02/2004)