Daly, Edward Thomas NEW YORK STATE DEPARTMENT OF HEALTH " `'.�r,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edward Thomas DalyMale
Date of Death Age If Veteran of U.S. Armed Forces,
3/18/2020 88 War or Dates Korean 1951-1953
Place of Death Hospital, Institution or
[City, Town or Village Town of ueensbu NY Street Address 33 Bonner Drive,Oueensbury,NY
Manner of Death 0 Natural Cause Accident Homicide Suicide EjUndetermined Pending
Circumstances Investigation
Medical Certifier Name Title
John E.Lukaszewicz MD
Address
N" 101 Ridge Street,Glens Falls, NY 12801
q Death Certificate Filed
District Number Register Number
City, Town or Village Town of Queensbury,NY 5(/rj417
❑Burial Date Cemetery or Crematory
March 21,2020 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
E
Hold
O Date Point of
IL ❑Transportation Shipment
p by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to
Name of Funeral Home Regan Denny Stafford Funeral Home Registration Number
01443
Address
53 Quaker Road,Queensbury,NY 12804
MM:
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 hum' r ns e e as indicated.
Date Issued -o�Registrar of V' al Statisti ,
(signal )
rj District Number_ Place
I certify that the remains of the decedent identified above re disposed of in a rdanc with this permit on:
W Date of Disposition 3-Z%-ZvzJ Place of Disposition ;)"j e ,,
W (address)
(section) Jot number) (grave number)
p Name of Sexton or Perso in Char of Premises �i4i/tow,,) I, a c4
Wplease print)
Signature J�� Title
(over)
DOH-1555(02/2004)
Public Health Law Sec. 4145(2b) 01.34,47
Receipt
Human remains of delivered on , 20
r,
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#