Georgi, Helene NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helene Georgi Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/29/2016 97 years War or Dates
of Death Hospital, Institution or
TcXXIXOt ArafICX Glens Falls Street Address Glens Falls, N Y 12801
.6. ' .nner of Death Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined Pending
ua Circumstances Investigation
W Medical Certifier Name Title
Ct David Foote M. D.
Address
340 A Main Street Hudson Falls, N Y 12839
h Certificate Filed District Number Register Number
Ci , Td ?Q( \WAX Glens Falls 5601 99
Burial Date Cemetery or Crematory
02/29/2016 Pine View Cemetery
❑Entombment Address
;'Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
- and/or Address
t= Hold
CD
0 Date Point of
IZ Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01117
Address
P O Box 277 Fort Ann, N Y 12827
Name of Funeral Firm Making Disposition or to Whom
I,r- Remains are Shipped, If Other than Above
;; Address
CC
ILI
Permission is hereby granted to dispose of the human remains described� above,as indicated.
Date Issued 02/29/2016 Registrar of Vital Statistics CLAsri f' o
"" WA
Or
(signatur )
• Ri 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:
ilt Date of Disposition 3 /(, Place of Disposition 4iut),tJ Cr+Ms oriw-
2 (address)
LU
CC (section) n (lot number (grave number)
its Name of Sexton or Person in Charge o Premises A(1- intar
(please print)
Signature `�` Title (R 0g.
(over)
DOH-1555 (02/2004)