Clancy, Marguerite 0 _ it I/ 17
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marguerite Elizabeth Clancy Female
Date of Death Age If Veteran of U.S. Armed Forces,
10 / 29 / 2017 95 War or Dates N/A
1,i,.. Place of Death Hospital, Institution or
Z City, Town or Village Moreau Street Address 19 Nolan Road
Ili
0 Manner of Death®Natural Cause E Accident 0 Homicide El Suicide Undetermined 0 Pending
Circumstances Investigation
0.
tu Medical Certifier Name Title
O. Glen Anderson MD
10 Address
1448 U.S. 9, Fort Edward, NY 12828
'> Death Certificate Filed District Number _ Register Number
�/
City,Town or Village Moreau 4/ a 6 g
Burial Date Cemetery or Crematory
10 / 31 / 2017 Pine View Crematory
I7Entombment Address
OCremation Queensbury, NY
Date Place Removed
Zri❑Removal and/or Held
and/or Address
42
Hold
V. Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
iiih Address
402 Maple Ave., Saratoga Sp. , NY 12866
tei
ipi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
111
"" Permission is hereby granted to dispose of the human re ins described above as indicated.
ill
Date Issued /6/6//1 7 Registrar of Vital Statistics ✓1 eLe�'�' _
(signature)
MI il! District Number c.71 c. oZ Place Moreau , New York
°'' ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 ,
f Date of Disposition I J ' 21 l Place of Disposition FMiti iso v�
ZE (address)
iii
W.
(section) , pot number) (grave number)
iQ Name of Sexton or Person in Charge f Premises . /I'L L ,14
Z (please print) .
Signaturetli / Title �[ ���(
(over)
DOH-1555 (02/2004)