Keefer, Grace .NEW,RYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Grace Keefer Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 6,2013 85 War or Dates
H Place of Death Hospital, Institution or
Z City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
p Manner of Death ❑_ Natural Cause Accident ❑Homicide El Suicide Undetermined 0 Pending
Circumstances Investigation
W, Medical Certifier Name Title
Q Eileen Spinelli
Address
9 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number _ Register Number
City,Town or Village Fort Edward , 75, S5""
®Burial Date Cemetery or Crematory
October 10,2013 Pine View Cemetery
Address
❑Cremation Quaker Road Queensbury,Queensbury,NY 12804
Date Place Removed
ZZ• ❑Removal and/or Held
and/or Address
H Hold
co
O Date Point of
N Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
O
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford 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
LZ
W t
a. Permission is hereby granted to dispose of the human rema s described above as indicated.
Date Issued/E)--,gib/3 Registrar of Vital Statis' ,3
(signature)
District Number � S� / Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 10
I/0(13 Place of Disposition / i,//' -aid a}ti �l V
2 (addrbss
c Id kelle,u k�cr1 '7/- 2-
OC (sectionn) (lot number) (grave number)
pName of on or Person in Charge of Premises Co ze. Z %a` t �m
W a�Pit)Signat IWl • .J.— Titl /C
(over)
DOH-1555(02/2004)