Esmond, Alice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
� Alice T. Esmond Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 4, 2011 79 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Lti
cc Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
lii Circumstances Investigation
Medical Certifier Name Title
Philip J. Gara MD Jr.
Address
327 Broadway,Fort Edward,NY 12828
Death Certificate Filed District Number egister N ber
City, Town or Village Fort Edward 3' 75 6
EI Burial Date Cemetery or Crematory
— December 7, 2011 Pine View Cemetery
— Entombment Address
Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I 'Removal and/or Held
2 and/or Address
H Hold
CO
0 Date Point of
coTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I I
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
2 Address
1C
ail
ci Permission is he eb granted to dispose of the human r ains described ove s indicated.
Date Issued // Registrar of Vital Statisti
-2 (signature)
District Number, Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ZPlace of Disposition Pine View Cemetery
Date of Disposition 1 2/7/1 1 P
2 (address)
W N Mohican 19 A 2
W (section) (lot number) (grave number)
in Name of Sexton or Person ip harge of Premises Michael Genier
Z 0. , — (please print)
W Signature JAA.LAA, Title Superi ntPnden_t
(over)
DOH-1555(02/2004)