Guyett, Agnes '..IN
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
x Agnes A. Guyett Female
$�: Date of Death Age If Veteran of U.S. Armed Forces,
0Aril 3, 2016 96 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death I XI Natural Cause Accident I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Carrie Miren RPAC
::: Address
ik' 9 Carey Road,Queensbury,NY 12804
-•.. Death Certificate Filed District Number Register Number
: City, Town or Village Fort Edward 5755 lV
Ii Burial Date Cemetery or Crematory
El Entombment April 7, 2016 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
:i:;1 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
xr Address
s: 53 Quaker Road, Queensbury, NY 12804
::::: Name of Funeral Firm Making Disposition or to Whom
IRemains are Shipped, If Other than Above
Address
::::::; Permission is hereby granted to dispose of the hum r ains descri ed ab s indicated.
": Date Issued L/_,5 0(4� Registrar of Vital Statistics 4..e V
(signature)
" District Number 5755 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 4/7/1 6 Place of Disposition Pine View Cemetery, Queensbury, NY
2 (address)
W
U Mohican 77C 1
(section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises Connie L. Goedert
(please print)
W SignaturFa-e-ei.--e-yrZTitle Cemetery Superintendent
(over)
DOH-1555(02/2004)