Farrington, Anna 4
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial _ Transit Permit
j Name First Middle Last Sex
Anna Farrington Female
::: Date of Death Age If Veteran of U.S. Armed Forces,
r:r December 21, 2015 64 War or Dates
kPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
g. Medical Certifier Name Title
Dean Reali
'6 Address
r r 100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 6 1 3
❑X Burial Date Cemetery or Crematory
December 23, 2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
t_' Hold
N
O Date Point of
N I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r:' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:1::::" Address
r• : 53 Quaker Road, Queensbury,NY 12804
Yx
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
., Permission is hereby granted to dispose of the human remains described above as indicated.
r Date Issued 1 Z 12- I I_5 Registrar of Vital Statistics LA3� .. ��^✓
(signatur'cce‘A-Aer
)
r"' 5601 Glens Falls
,ti•;. District Number Place
} I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition 1 2/23/1 5 Place of Disposition Pine View Cemetery, Queensbury, NY
W (address)
W Mohican 18J 2
O (section) (lot number) (grave number)
QName of Sex n or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signature- -LP -L LL4 ( Title Cemetery Superintendent
(over)
DOH-1555(02/2004)