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Farleigh, Etta NEW YORK STATE DEPARTMENT OF HEALTH •' Vital Records Section Burial - Transit Permit Name First Middle Last Sex Etta Lousie Farleigh Female - Date of Death Age If Veteran of U.S. Armed Forces, 04/02/2018 89 Years War or Dates Place of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Manner of Death©Natural Cause El Accident El Homicide Suicide 0 Undetermined ri Pending Circumstances Investigation Medical Certifier Name Title Thomas Kandora MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City, Town or Village Fort Edward 5755 15 ❑Burial Date Cemetery or Crematory 04/02/2018 Pine View Crematory ❑Entombment Address ®Cremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of g i=Q Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 k" 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. Date Issued 04/03/2018 Registrar of Vital Statistics Aimee IKakoney(ECectronicallySigned) (signature) District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 9 Date of Disposition to 3 11� Place of Disposition ,Iw .,r (address) (section) (lot number) (grave number) Name of Sexton or Person in Charge of P emises / Ira (phase print) Signature u` Title (04TWL (over) DOH-1555 (02/2004)