Irmie, Fannie NEW YORI< STATE DEPARTMENT OF HEALTH
Vigil 1lecutcls Ser.liou
_ _
a:r.t11111rfBT!}7{R�
Name Fitsl -
- Middle
FANNIE IMRIE Last g�x
Dale of Ueatli - - -- - I Female
Jan 28t 1999 Aye 1f Veteran of U.S. Atrrtecl Forces,
94 War or Dates none
K. Place of Death
-- `- Hospital, Instituliuri or
• City, Town or Village Queensbury, NY Sheet Address Hallmark Nursing Centre
Mamn,er of Death - --- - -
� Nnlutal Cause Il Accident n Homicide Suicide n Undetermined ri Pending
Citcun,slances Investigation
Medical Certifier Name - TitlefP y
Thomas_Kandora, M.D.
Address
152 Sherman Ave. GF, NY
Death Certificate riled District NUlrber Register Number
City, Town or Village Queensbury, NY 5657 -D�
_e Date Cemetery or Crematory
t! Bum''0, l January 30, 1999 Pine View Cemetery
n Address- ----
)Cremation Quaker Rd Queensbury, NY
Date Place Removed
V Removal _ and/or Held
and/or Address - -
Hold
Q Dale- -_. Point of
V7 Transportation -- Shipment
L1• by Common Destination
Carti9r
[�Disinlern,enl- "Date - - - Cemetery Address ..
Dale Cemetery Address
n Reinlermnetit
Permit Issued to Registration Number
': (Jame o1 Funeral Home Sullivan-Minahan & Potter Funeral Home 01837
§; Address
ill
_ 407 Bay R_d Queensbury, NY 12804
Name of Funeral Finn Making Disposition or to Whom
M Remains are Shipped, II 011ie, than Above
Address --- ---
ir.og
IP
: ' ::;
ri Is hereby granted to dispose of the human ns demi in loaf d.
1/29/99 Registrar of Vital Stalisli Cl__ CL-N
(signatu►e)
`. Uisttict Nun,bet 5657 Place Town of Qu s ury, NY 12804
I cetlily that the Ie►nains of the decedent Identified above were disposed of in accordance will, this permit on:
F.
Date of Disposition 1 /30/99 Place of Disposition Pine View Cemetery ; Queensbury . NY
(addiess)
Hudson #3 10-C 1
(section) (lot number) (grave number)
O Name of Sexl n or Person in Cl tat ge of P,emises Rodney G . M osher
R.: (please 'mitt!)
W. Signatur ltr-v Title Superintendent
DOH-1555 (10/89) p. I of 2 VS-81