Davidson, Ethel 4
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
,; Ethel Davidson Male
% Date of Death Age If Veteran of U.S. Armed Forces,
,''< December 5, 2013 74 War or Dates
Place of Death Hospital, Institution or
Z, City, Town or Village Queensbury Street Address 21 Stewart Rd.
Manner of Death X Natural Cause Accident n Homicide n Suicide n Undetermined Pending
1"s
Circumstances Investigation
Medical Certifier Name Title
Gerard Abess MD
Address
f 3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 I `1
❑X Burial Date Cemetery or Crematory
❑Entombment December 11,2013 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
Z n Removal and/or Held
2 and/or Address
H Hold
CO
O Date Point of
['Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n 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
'1' Remains are Shipped, If Other than Above
: t tAddress
Permission is hereby granted to dispose of the human re ains described Bove as indicated.
,> " Date Issued 1la 1c Registrar of Vital Statistics ( . Lin a�_,
,,f (signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
imDate of Disposition 1 2/1 1 /1 3 Place of Disposition Pine View Cemetery
Ill (address)
U) Mohican 59D 2
(section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises Connie T._ (,npr3Prt
/�' (please print)
w SignatureLiô/t,wi �. ,.PGiir6 Title Superintendent
(over)
DOH-1555(02/2004)