Eggleston, Nieta NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
Name First Middle Last Sex
Nieta Shirley Eggleston Female
> Date
:..of::.. .:::::.................................................... .................. ............................................................................
Death Age If Veteran of U.S.Armed Forces,
12-22-88 40 War or Dates no
Z Place of Death Hospital, Institution or
iw City,Town or Village Street Address
tl : 9 City of Glens Falls Glens Falls Hospital
Cause of Death
Respiratory Arrest
itt Medical Certifier Name Title
G Gary A. Rath, M.D. Medical Physician
Address':::::............................................................................................. ......................................................................................................
Mii
17 Pine Street, Glens Falls, NY 12801
.::Death Certifioate:::.;: .................................................................. .. .................................................... ..........................
Filed District Number Register Number
City,Town or Village City of Glens Falls
Date Cemetery or Crematory
®Burial 12-27-88 Pine View Cemetery
0 Cremation Address
Queensbury, NY 12804
z Date € Place Removed
Q ❑ Removal and/or Held
and/or Hold ::::::::.:::::::::.:::.:::::::::::::::::::::::::::::::::.::::::::::::::::::::::::::......::::::::::::.::::::::::::::::::............:::::::::::::::::::::::::::::::........:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Address
tn
0. Date Point of
cn ❑Transportation by': Shipment
Common Carrier
..............................................................................................................................
Destination
......................................::�::::Date
::::::....................................................::::,�Ceniete Address
::::::...................................................................................................
.„ El Disinterment
ry
.......................................... ......................................................... meteAddress
:::::...................................................................................................
❑ Reinterment Date Cemetery
Permit Issued to Registration Number
Name of Funeral Firm Regan & Denny Funeral Service, Inc. 02883
Address:::::................................................................................................................................................................................................................................................
im
40 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Makiing Dis:osition or to WhofT1.,::::.......................................................................................................................................................
449 Po
:'2 Remains are Shipped, If Other than Above
:t1w....Address
AU
Permission is hereby granted to dispose of the hu n emains described above s indicated.
iiii Date Issued Registrar of Vital Statistic i f� s..�..c.c.)
�(ssiiiggnature) �/
District Number k. �0/ Place ,/ 7GGGCC� // fo/
iw
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1- ---,
Date of Disposition . Place of Disposition T d ? r Ne 7.^ i c' ) C Kra c cY 11 ....,rus t,..�
la
2 (address)
CC, (section) (lot number) (grave number)
a• Name of Sextor�Jar�rson in Charge of Premises �R� T� a+ Y YLel. �-.�i.
Z ` / `- (please print) 1
- Signature 1 . oc A/te.... /h Title 5V FT
DOH-1555(9/86)p 1 of 2(formerly VS-61)