Davignon, Edith NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last . Sex
Edith M. Davignon Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/27/99 83 War or Dates No
:ii
fi4 Place of Death Hospital, Institution or
2 City, Town or Village Queensbury Street Address Hallmark Nursing Center
lii
Manner of Death Natural Cause Accident Homicide �Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Thomas Kandora ND
Address
Hallmark Nursing Center Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury j(ps''l I a-t
Date Cemetery or Crematory
Burial 12/1/99 west Glens FAlls Ce.
Address
❑Cremation Queensbury,NY
Date Place Removed
0❑Removal and/or Held
•`• and/or Address
Hold
0 Date Point of
yQ Transportation Shipment
5 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<` Permit Issued to Registration Number
Name of Funeral Home Sullivan Minahan & Potter 01824
O Address
111 407 Bay Rd. Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
RRemains are Shipped, If Other than Above
Address
Ol Permission is hereby granted to dispose of the human r 'ns d ' ed a e as indicated.
ie
f€ Date Issued 12/1/99 Registrar of Vital Statistics a,' C,
nature)
o District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f�-
6 Date of Disposition12/1/99 Place of Disposition West Glens Falls Cemetery , Queensbury , NY
', (address)
Family Plot
CC (section) (lot number) (grave number)
0 Name of Sext or Person in Charge of Premises Rodney G . Mosher
CI
g (please print)
W Signature trza_p -J% . , Title Superintendent
(over)
DOH-1555 (9/98)