Vickery, Edna NEW YORK STATE DEPARTMENT OF HEALIT
Vital Records Section Burial - Transit Permit
Name First Mtdale Last Sex
Edna Ruth Vickery Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/23/2018 94 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
Manner of Death X❑ Natural Cause ❑Accident Homicide ❑Suicide ri❑ Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
John Quaresima MD
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 178
Date Cemetery e�€�['Burial or Crematory
12/26/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held and/or
Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
R Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
(
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
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 human remains described above as indicated.
tiA Date Issued 12/26/2018 Registrar of Vital Statistics Caroline II-Barber(Electronically Signed)
(signature)
$ District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ))..-m� _ i& Place of Disposition ;nt., 1/r„1,/ Jed's-0 WY
(address)
(section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises vecn,-t.y 5E,ras
(please print)
Signature i/ ...I_ _,, Title
c,f <:4or
(over)
DOH-1555 (02/2004)