Raych, Annette NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
1, City,
AnnetteRa ch Female
Date of Death If Veteran of U.S. Armed Forces,
Se tember 7 2017 97 War or Dates
Place of Death Hospital, Institution or
Town or Village Moreau Street Address Home Of The Good Shepard
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John Sawyer
Address
161 Carey Rd,Queensbury,NY 12804
Death Certificate Filed District Number egist r Number
> : City, Town or Village Moreau 4562
0 Burial Date Cemetery or Crematory
September 11 2017 Shaara Tefila
El Entombment Address
❑Cremation Media Drive ueensbur , NY 12804
Date Place Removed
Z FI Removal and/or Held
0 and/or Address
Hold
N
p Date Point of
Transportation Shipment
Q by Common Destination
Carrier
Date Cemetery Address
Disinterment
Renterment Date Cemetery Address
r Registration Number
Permit Issued to
>: 1443
Name of Funeral Home Regan DennyDenn Stafford Funeral Home
Address
< 53 Quaker Road, Queensbur , NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address I
m [ /5 ed
,/N—w )19J
Permission is hereby ranted to dispose of the human remains escribed bov& as indicated.
Date Issued D� Registrar of Vital Statistic
(sign ure)
District Number 4562 Place Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition )J 1-7 Place of Disposition 11Cy11 44,,
2 (address)
W
cc
ac (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises
Z �' /" (Please print)
W Signature � Title
(over)
DOH-1555(02/2004)