Edmunds, Ola # is 5
NEW YORK STATE DEPARTMENT OF HEALTH I 4
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ola Louise Althiser Edmunds Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/17/2011 99 years, War or Dates
l Place of Death Hospital, Institution or
Li City, TowRyil Glens Falls Street Address Glens Falls Hospital
Manner of Death mural Cause 0 Accident 0 Homicide El Suicide 0Undetermined ri Pending
Circumstances Investigation
Cj
tu Medical Certifier Name Title
Richard P I each M D.
Address
One Irongate Plaza Glens Falls, N Y 12801
Miii Death Certificate Filed District Number Register Number
City, Tows j(illvrgRXX Glens Falls 5601 231
:::0Burial Date Cemetery or Crematory
❑Ent bment 05/19/2011 Pine View Crematorium
Address
mation Queensbury, NY 12804
Date Place Removed
1 El Removal and/or Held
S and/or Address
h=" Hold
0 Date Point of
fk0 Transportation Shipment
d by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01464
:: Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
re
Lti
CU
Permission is hereby granted to dispose of the hum remain descri d above as ndic= ed.
iiiii
Date Issued 05/19/2011 Registrar of Vital Statistics . � A G
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
//
W Date of Disposition 5 /toil Place of Disposition ,p,14 t/ C 6'c
(address)
COin
lr (section) t (lot nurrm r) (grave number)
0
el Name of Sexton or Per n in Charge f Premises L r.5C�r -1..1.4
' , (please print)
Signature I Title CRgvIljla
(over)
DOH-1555 (02/2004)