Norton, Blanche NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Blanche M. Norton Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 8, 2017 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death ' Natural Cause ❑Accident n Homicide n Suicide 1 Undetermined n Pending
Circumstances Investigation
€ Medical Certifier Name Title
Carrie Miren RPAC
Address
9 Carey Road,Queensbury,NY 12804
f Death Certificate Filed District Number Registqumber
City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
March 10,2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
z C Removal and/or Held
0 and/or Address
! Hold
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O Date Point of
Nd n Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
0°' ; Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
=f 53 Quaker Road, Queensbury,NY 12804
ter)
. Name of Funeral Firm Making Disposition or to Whom
.-. Remains are Shipped, If Other than Above
N Address
:0 Permission is he eby granted to dispose of the human - ins described above a indicated.
Date Issued 7 Registrar of Vital Statistic•. �� iP_(
: (signature)
District Number 5755 Place Fort Edward
I▪ certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Place of Disposition P reed C/2r /
W Date of Disposition ,� J3 /°� P !Yt�t1�
/ (addre$)
Cl)ill
Le (section) t (lot number) (grave number)
0 1
p Name of Sexton erson in Charge of Premises f„./ c.,.t - a- h.
`Z (please print)
Signature + �._ Title �/L✓7+- .-
(over)
DOH-1555(02/2004)