Monthony, Geraldine . # ci
NEW YORK STATE DEPARTMENT OF HEALTH _ `
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Geraldine S. Monthony Female
Date of Death Age . If Veteran of U.S. Armed Forces,
5-15-2011 89 War or Dates N/A -
14 Place of Death Hospital, Institution or
Z Qkx,nomecoxVillage Ballston Spa Street Address Maplewood Manor
Manner of Death Natural Cause Accident L Homicide 0 Suicide n Undetermined Pending
W Circumstances Investigation
jj Medical Certifier Name Title
P Stephen Strader MD
Address
61 Rowland Street, Ballston Spa, New York 12020
Death Certificate Filed District Number Register Number
i>: XXV.Zawl3CHr Village Ballston Spa 4520 19
io.❑Burial Date Cemetery or Crematory
„ ❑Entombment 5-17-2011 Pineview Crematory
Address
®Cremation Queensbury, New York
Date Place Removed .
r-1 Removal and/or Held
P 1 1 and/or
it Hold
Hold
VI
0 Date Point of
fl Transportation Shipment
. by Common Destination
Carrier
+Disinterment Date Cemetery Address
Reinterment -
Date Cemetery Address
:ali- Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00442
Address
7 Sherman Ave, Cornith, New York 12822
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
M. Address
,!1
1 Permission is hereby granted to dispose of the human remains described� above as indicated.
Date Issued 5-16-2011 Registrar of Vital Statistics \�� /LJ2 , L
(signatur)
District Number 4520 Place Village of Ballston Spa, Ne ork
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ,F
W Date of Disposition 5--it-L( Place of Disposition Fift Y t ay.) (,Ccha o lu
(address)
U
U)
r (section) (lot�'ber) (grave number)
CI Name of Sexton or P son in Char of Premises r,s-1 P1Vr J0.,,eit
(please print)
!it Signature II Title cac-m l oL
(over)
DOH-1555 (02/2004)