Verner, Abbie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Abbie S Verner Female
ni Date of Death Age If Veteran of U.S. Armed Forces,
PS 01/25/2017 79 years War or Dates
P of Death Hospital, Institution or
Z Ci (Met MOM Glens Falls Street Address Park St Glens Falls, N Y
anner of Death i Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
LAI Medical Certifier Name Title
William Cleaver Attending Physician
Address
100 Park St Glens Falls, NY 12801
Q. Death Certificate Filed District Number Register Number
g:ii ESP Tam Glens Falls 5601 61
hi
❑Burial Date Cemetery or Crematory
01/26/2017 Pine View Cemetery
q:iiiii❑Entombment Address
: '.. Q'Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
0.0 and/or Address
h= Hold
0
0 Date Point of
Q` Transportation❑ p Shipment
i by Common Destination
pi Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Stuart-fortune-keough Funeral Home 01640
Address
24 Cliff Ave Tuppere Lake, Ny
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
X.
to
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/26/2017 Registrar of Vital Statistics ( J C%llvrv`&
(signature)
1. District Number 5601 Place Glens Falls N tp
tI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
di p
Date of Disposition- I/t,f 17 Place of Disposition e[)o�,F„I fern' t{fc�-^
(address)
ja
2 (section) (tot number) (grave number)
Name of Sexton or Person in Charge of Premises L waft
btr 3a+4 it(phase print)
Signature �1 o� Title CR 14tilb L
(over)
DOH-1555 (02/2004)