French, Vickie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vickie M. French Female
Date of Death Age ! If Veteran of U.S. Armed Forces,
9/20/2018 61 j War or Dates NA
1. Place of Death Hospital, Institution or
I
Z City, Town or Village Town of Moreau,NY Street Address 9 Flushing Ave,S.Glens Falls,NY
Wp Manner of Death [ Natural Cause [—Accident pi Homicide [Suicide Undetermined n Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Edward M.Liebers MD
Address
3 Care Lane,Suite 300,Saratoga Springs,NY
Death Certificate Filed District Number 1 Register Number
City, Town or Village Town of Moreau,NY 4/5 2 y'j
El Burial Date Cemetery or Crematory
September 27, 2018 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z —Removal I and/or Held
and/or Address
H Hold
N
o _ Date Point of
O.
_Transportation Shipment
p by Common Destination
Carrier
E Disinterment Date i Cemetery Address
(-i Renterment Date Cemetery Address
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
1— Remains are Shipped, If Other than Above
2 Address
GC
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9) 21)/ i Registrar of Vital Statistics /0 ci€1-_S c—
(signature)
District Number C./ 56 ' Place j 004 Q t° /I?D ,Cf a.w
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 j 1l lig Place of Disposition .eei}1„-, Add-
2 (address)
iY (section) !1/ pot numbP(l (grave number)
QName of Sexton or Person in Charge of Premises j'. i L 4-.it
Z 4 (please print)
W Signature rn.[ Title ( (M ,
(over)
DOH-1555(02/2004)