Waterston, Hulda It
NEW YCOkill STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
Hulda M. Waterston Female
.:. : Date of Death Age If Veteran of U.S. Armed Forces,
:40•:-* January 4, 2016 95 War or Dates
r• Place o Death Hospital, Institution or
City, own r Village j :,k n5 L, Street Address Tri County Nursing Home
: Manner of Death g Natural Cause Accident I Homicide Suicide Undetermined Pending
Circumstances Investigation
: Medical Certifier 1Name Title
;.;;; Jas Hindson,MD
r' Address
: :� North Creek Health Center,Johnsburg,NY % i' L/3
fr Death Certificate Filed District Number Register Number
,•. City, Town or Village
❑Burial Date Cemetery or Crematory
El Entombment January 5, 2016 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I !Removal and/or Held
2 and/or Address
�' Hold
N
O Date Point of
coTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i :: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:' Address
53 Quaker Road, Queensbury,NY 12804
:::▪ Name of Funeral Firm Making Disposition or to Whom
> : Remains are Shipped, If Other than Above
Address
Permission is herebygranted to dispose of the human m 'n describe above .
r f: ) p a s esc be Gated
Date Issued J.-6• Registrar of Vital Statistics L V
::::: (signature
:K District Number 54) Place 1 out.)0 4 J lA,ut
::::;::
I certify that the remains of the decedent identified above were disposed of in accorda a with this permit on:
Z
W Date of Disposition /-7-/63 Place of Disposition //�j e U j 2v Cr-ci-nefv,zi
ill
(address)
CO
tr (section) (lot number)
° it,-1 p Name of Sexton or erson i Charge of Premises ;�n �, (grave number)
1--
Z (please print)
W
Signature Title Gce-fryie e-�
(over)
DOH-1555(02/2004)