Fleming, AnnaNEW YORK STATE DEPARTMENT OF HEALTH v
Vital Records Section urial - Transit Permit
Name First Middle ast I Sex
Anna R. Fleming _ __ Female
Date of Death Age I If Veteran of U.S. Armed Forces,
95 War or Dates
F.
_9/30/_2019
Place of Death Hospital, Institution or
Z
City, Town or Village QueensburyStreet Address 18 Farr Lane East Apt 206
pManner
of Death � ❑ ❑ Natural Cause Accident Homicide Suicide Undetermined Pending
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Circumstances Investigation
V
Medical Certifier Name Title
G
Robert French MD
Address
Death Certificate Filed
District Number
t
"enirder
Number
City, Town or Village Queensbury
5657
❑ Burial
Date Cemetery or Crematory
El Entombment
October 2, 2019 Pine View Crematorium
-Address — - ----- ---
® Cremation
51 Quaker Road, Queensbury, NY 12804
Date
Place Removed
ZZ
❑ Removal
and/or Held
and/or Address
H
Hold
0
Date Point of
N❑
Transportation Shipment
p
by Common
Destination
Carrier
❑ Disinterment
Date Cemetery Address
Date Cemetery Address
❑ Renterment
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
H
Remains are Shipped, If Other than Above
Address
W
—
a
Permission is hereby granted to dispose of the human remmaai+ns abp a as indicated.
-described
Date Issued r �j Registrar of Vital Statistics "" k'L,
aT
_ (signature)
District Numbe Place
I certify that the remains of the decedent identified above were disposed of in accord ce ith this permit on:
W
Date of Disposition !oil Ili Place of Disposition
W
(address)
N
(section) (lot number) (grave number)
pName
of Sexton or Person in Charge of Premises t�i}p�t.., w►ll1
W(please
print)
Signature ZTitle (ft4 A-TDq
DOH-1555 (02/2004)
(over)
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i
i
Public Health Law Sec. 4145(2b)
U125�75�
Receipt
1 f 1.
Human remains of ��� �� � � �`� � t �: ;delivered on , 20_
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Pine View Cemetery
Official
Representing the funeral home nam oq b rial�ermit
Funeral Directors Reg. or License #