Merritt, Patricia 4' NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Patricia L. Merritt female
>': Date of Death Age If Veteran of U.S. Armed Forces,
May 11, 1995 51 War or Dates no
Place of Death Hospital, Institution or
City, Town or Village City of Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident ❑Homicide ❑Suicide �Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
1 Nancy D. Carney MD
Address
Warrensburg Helath Center, Warrensburg, New York 12885
Death Certificate Filed District Number Register Number
Ni City, Town or Village City of Glens Falls 3
Date Cemetery or Crematory
®Burial May 16, 1995 Gurney Lane Cemetery
Address
❑Cremation Queesnbury, New York
Date Place Removed
0 Removal and/or Held
r- and/or Address
• Hold
Ch
0 Date Point of
y ❑Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ii Permit Issued to Registration Number
Name of Funeral Home Reiiii] gan and Denny Funeral Service, Inc. 01583
Address 53 Quaker Road, Queensbury, New York 12804
''" Name of Funeral Firm Making Disposition or to Whom
sot Remains are Shipped, If Other than Above
Address
W
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Mi Date Issued, 1 IJ/ Registrar of Vital Statistics i-fie,i : OA•A-K-L ri�'�
(signature)
e`
District Numbed K9/ Place ��)27-6:--u4 g2d..1 /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
tij Date of Disposition Place of Disposition
2 (address)
uJ
CC (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises
z (please print)
Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61