Heydrick, Myla NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section . . Burial - Transit Permit
pi Name First Middle Last Sex
gi
Myla A. Heydrick Female
Date of Death Age If Veteran of U.S. Armed Forces,
II Aug. 10, 2017 g .' War or Dates n/a
j Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death®Natural Cause El Accident 0 Homicide Ei Suicide riUndetermined ri Pending
Circumstances Investigation
41 Medical Ctiiertifier Name Title
CI Asim Chaudy MD.
Address
' `'l 100 Park St. , Glens Falls, NY. 12801
iilii Death Certificate Filed District Number Register Number
iiiig City, Town or Village Glens Falls 5601 1l'i�
Date Cemetery or Crematory
❑Burial Aug. 1 1 , 2017 PineView Crematorium
Address
ElCremation Quaker Rd. , Queensbury, NY. 12804
Date Place Removed
0❑Removal and/or Held
-• and/or Address
aHold
Date • Point of
02❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date. Cemetery Address
::::: Reinterment Date Cemetery Address
iiiPermit Issued to Mason Funeral Home Registration Number
mi Name of Funeral Home 01 1 17
iiiiii Address
iiiiiii
18 George St. , Fort Ann, NY. 12827
,.. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
SI Address
W
iE Permission is hereby granted to dispose of the human remains described above as indicated.
`
iiiiii Date Issued 8/1 1 /1 7 Registrar of Vital Statistics 0
(signature)
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
tiri Date of Disposition Place of Disposition {%,idUa.-- e aA--
2 (address)
LU
CC (section) ?,number) C (grave number)
Name of Sexton or Person in Charge of Premises �1dN
g6 2 (please print)
Signature Title Cr
(over)
DOH-1555 (9/98)