Dyer, Edith NEW YORK STATE DEPARTMENT OF HEALTH
Er19 70
Vital Records Section Burial - TransitPerml�� .4 t
gig Name First Middle Last Sex
', Edith Agnes Dyer Female
Date of Death , Age If Veteran of U.S. Armed Forces,
January 141, 2017 99 War or Dates n/a
Via. Place of Death Hospital, Institution or
:: City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
'f:• Manner of Death Ti Natural Cause ❑Accident n Homicide Suicide n Undetermined n Pending
Circumstances Investigation
?< Medical Certifier Name Title
•: Michael Fuller,MD
ei Address
Glens Falls,NY
-44
Death Certificate Filed District Number Register Number y�-`
City,51 Town or Village 7
9 Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
January 23, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
o and/or Address
E Hold
0 Date Point of
filj Transportation Shipment
a by Common Destination
Carrier
['Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
f 53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
,/, Date Issued 1I 2-O/2-6/7 Registrar of Vital Statistics CA-Lry -St.
(signa re)
itDistrict Number 5 60i Place 6 6,./vsV s 7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I j ? (f ri Place of Disposition ffteU c4orti..
W (address)
W (section) // (lot num ) (grave number)
pName of Sexton or Person in Charge of Premises R ct Citittriiv&f
Z (p)base print)
W
Signature44_
Title Cio k9)/L
(over)
DOH-1555(02/2004)