McWain, Crystal NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ,_ c- Burial - Transit Permit
_
Name First Middle Last Sex
Crystal .1-_ M,cwa; n Female
Date of Death Age If Veteran of U.S. Armed Forces,
Dc 24, 2018 63 yrs. - War or Dates n/a
1,► Place of Beath Hospital, Institution or
W City, Town or Village Fort Edward Street Address 353 State Rte. 1 97
W Manner of Death Natural Cause ❑Accident Ili Homicide El Suicide ri❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
D
Address
Death Certificate Filed District Number,.-ri 65 Register Ne r
City, Town or Village Fort Edward ____ ' `
❑Burial Date Cemet@ay or Crematory
Dec. 26, 2018 PineView Crematorium
❑Entombment Address
.. Cremation Queensbury, NY_ 12R04
Date Place Re, loved
❑
Removal and/or Held
9 and/or
loi Address
Hold
f.P4 Date Point of
li 0 Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Mi Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 0111 7
Address
18 GGeorg Ski. Fart 1Ann tNY 12827
Name of Funera irm aI<ing isposi ion 6r o hom
Remains are Shipped, If Other than Above
• Address
Ili
CL
E.i Permission is hereby granted to dispose of the huma r aips describe ove a ndicated.
ill Date Issued 1 2/26/1 8 Registrar of Vital Statistics
(signature)
District Number5g5 Place Town of Fort Edward, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition j Place of Disposition p, CA Atlhry,
(address)
Ili
CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises j dr-e-y j cod ii, C
(please print)
r. Signature 1 Title Cfc,M9 icy
(over)
DOH-1555 (02/2004)