McLoughlin, Myrna NEW YORK STATE DEPARTMENT OF HEALTH -
Vital Records Section -, Burial - Transit Permit
: s Name First
Middle Last Sex
<s' Myrna Ann McLoughlin Female
`N. Date of Death Age If Veteran of U.S. Armed Forces,
.>:< August 8, 2017 86 War or Dates
xgg,�. Place of Death Hospital, Institution or
{ City, Town or Village Queensbury Street Address 122 McCormack Drive
Manner of Death Natural Cause El Accident Ei Homicide r7 Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Alicia Earley, PA
11 Address
t" Queensbury,NY
aa,. Death Certificate Filed District Number Register Number
imij
r City, Town or Village Queensbury,NY 5657 1 0?--
❑Burial Date Cemetery or Crematory
El Entombment August 14,2017 Pine View Crematorium
Address
®Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
z ❑Removal and/or Held
and/or Address
F Hold
Cl)
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
`..; Permit Issued to Registration Number
`r`:f Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rfr Address
f:? 53 Quaker Road, Queensbury,NY 12804
'' Name of Funeral Firm Making Disposition or to Whom
': Remains are Shipped, If Other than Above
Address
Ii
r ? Permission is hereby granted to dispose of the human re d s d ( as indi d.
>��1j
1+V1 Date Issued 9f_n[—o��t'1 Registrar of Vital Statistics �p
i,a
. :: (signature
.. .
i. District Number S(,S1 Place 4, y 0
I certify that the remains of the decedent identified above ere disposed of in accordanc wit this permit on:
Z
W Date of Disposition $11SItJ Place of Disposition Fin, 674,,,cst0riw..
2 (address)
W
CD
Ce (section) of ngwber) (grave number)
pName of Sexton or Person in Charge of Premises 1r.'1 .N imit-
Z / (pteasb print)
W 4
Signature ! Title tri Wig,
v
(over)
DOH-1555(02/2004)