Lemery, Andrea NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Andrea J. Lemery i Female
Date of Death Age If Veteran of U.S. Armed Forces,
:.i▪l May 4, 2011 64 War or Dates N/a
N : Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
esManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
f Medical Certifier Name Title
Philip Gara,MD
_ Address
::1 Fort Edward,NY
Death Certificate Filed District Numbe Register Number
City, Town or Village Town of Fort Edward,NY —55675
0 Burial Date Cemetery or Crematory
❑Entombment May 10, 2011 j Pine View Cemetery
Address
Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
C and/or Address
H Hold
Cl)
a Date Point of
N Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
1 Reinterment
Date Cemetery Address
:.:.:.:.r Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home -, 01622
• Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
.ek Remains are Shipped, If Other than Above
.X; Address
:: Permission is h reb granted to dispose of the human r ins described above s indicated.
Date Issue.ir,,f.lp // Registrar of Vital Statistic
signature)
• District Number57 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:
2US Date of Disposition 5/10/11 Place of Disposition Pine View Cemetery
(address)
OTC Erie 72A 2
-
(section) (lot number) (grave number)
p Name of Sexton or Pers i Charge of Premises Michael Genier
Z 1 (please print)
W Signature .A,M.t.�� Title Superintendent
(over)
DOH-1555(02/2004)