Warnken, Maryann 4t7 , 27/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
'f Name First Middle Last Sex
Maryann Warnken Female
Date of Death Age If Veteran of U.S. Armed Forces,
;r April 7, 2016 92 War or Dates NA
Place of Death Hospital, Institution or
' City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
ti Manner of Death X Natural Cause Accident n Homicide Suicide
Title Undetermined Pending
Circumstances Investigation
Medical Certifier1
Name
Bernardo Villajia MD
Address
319 Broadway Fort Edward,NY 12828
.# Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward -6755- /7
❑Burial Date Cemetery or Crematory
April 8, 2016 Pine View Crematorium
Ill Entombment Address "
0 Cremation 51 Quaker Road,Queensbury,NY 12804
Date Place Removed
2 Removal and/or Held
and/or Address
H Hold
U
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
qRegiPermit Issued to
stration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
egii. Address
:: 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
,t,,. . Permission is h eb granted to dispose of the human r- s described above as . dicated.
r Date Issued / Registrar of Vital Statistic-.
;.ti: (signature) 7
1A;' �District Number�7� Place /114,-? / -t l/2, oZ
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition K/(Z(((, Place of Disposition 21.- Cr+y-lyipJ,
W (address)
co
ix (section) ,,((lot number "_ '1 (grave number)
ap Name of Sexton or Person in Charge of Premises r r 1..,,
Z (obese print)
W
Signature ,ass Title r?M }fl//
(over)
DOH-1555(02/2004)