Simon, Eileen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
.k Name First Middle Last Sex
Eileen R. SIMON Female
:::i1 Date of Death Age If Veteran of U.S. Armed Forces,
7/6/2015 85 War or Dates no
1- Place of Death Hospital, Institution or
W Ca, Town i MAXIM Lake Luzerne Street Address 176 Scofield Rd.
p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
p John Stoutenburg M.D.
Address
Glens Fails, NY
,x K
Death Certificate Filed District Number Register Number
0.14 l x Town NfAXIMMX Lake Luzerne 5656 /2)
❑BurialDate/ 7/201 5me iee oe rYrn
❑V. Entombment Address
®Cremation Queensbury, NY
triDate Place Removed
Q ❑Removal and/or Held
and/or Address
~ Hold
03
Date Point of
N ❑Transportation Shipment
a by Common Destination
C51 , arrier
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
A Permit Issued to Registration Number
U Name of Funeral Home Brewer Funeral Home, Inc. 00211
Address
.ma
.. 24 Church St. , Lake Luzerne, NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
rt
111
s Permission is hereby granted to dispose of the human r ins des ibed ab ve as indicated.
l'-' Date Issued°?6 7-/ istrar of Vital Statistics X Ql./,0--eg-
l':
(si nature)
i District Number ��,j� Place /6� Zz_7,2/f�.
I certify that the remains of the decedent identified above h e disposed of in accordance with this permit on:
I-1
Z W "C�Date of Disposition l f�/It Place of Disposition �µ ,,,✓ C..e-i(v...-
(address)
tU
U)
ce (section) 1/(lot number) r (grave number)
Z Name of Sexton or Person in Charge of Premises (1� �[
(pease print)
Lll Signature Title 4 NfWZ.
(over)
DOH-1555 (02/2004)