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Andersen, Edna NEW YORK STATE DEPARTMENT OF HEALTH a iVital Records Section ;, Burial - Trans ��ermit Name First Middle Last Sex Edna Andersen Female Date of Death Age If Veteran of U.S. Armed Forces, February 4, 2016 89 War or Dates Vietnam Korea F Place of Death ' Hospital, Institution or Z City, Town or Village11J Glens Falls Street Address Glens Falls Hospital 0 Manner of Death Fri Eli Natural Cause ❑ Accident ❑ Homicide ElSuicide ElUndetermined ❑ Pending tW Circumstances Investigation W, Medical Certifier Name Title CI Julian Marynczak, Nf Address /no payLSt. , C I &s �fi- ,.tls A.+y 12E't�( ath Certificate Filed District Number Register Number i , Town or Village Gt2v15 [IS 5601 (; 5 urial Date Cemetery or Crematory February 8, 2016 Pine View Crematorium 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal z ❑ and/or Held and/or Address E, Hold GERALD B.H. SOLOMON NAT. Date Point of GEM. e ❑Transportation Shipment CO? by Common Destination Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above XAddress Illa.' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued , J 4 J 1 (, Registrar of Vital Statistics W` .'" s ` + (signature) District Number 5601 Place e (..giv-‘. S c-c.), t ` N, u' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 02/08/2016 Place of Disposition Quaker Road Queensbury,NY 12804 p;nZV.e,,d u-f:r," (address) W In Wall CO IX (section) (lot number) (grave number) aName of Sexton or Person in Charge of Premises JesW' Y f A),f t5 z (please print) alSignature / l Title C-d('e„r^cicc-. (over) DOH-1555 (02/2004)