Peabody, Alice //
NEW YORK STATE DEPARTMENT OF HEALTI1'. ' * �gl
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Alice R. Peabody Female
Date of Death Age If Veteran of U.S. Armed Forces,
r::: September 18, 2015 89 War or Dates
err Place of Death
i Hospital, Institution or
City, Town or Village Gansevoort Street Address Home Of The Good Shepard
Manner of Death
R Natural Cause I Accident Homicide Suicide Undetermined Pending
rr.r Circumstances Investigation
: Medical Certifier Name Title
John Sawyer M.D.
Address
r•:: 161 Carey Road,Queensbury,New York 12804
�•r
:r:r Death Certificate Filed District Number Register Number
r City, Town or Village
❑Burial Date Cemetery or Crematory
September 18,2015 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
F Hold
N
0 Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
.};
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
rrr:; Address
:r 53 Quaker Road, Queensbury,NY 12804
rK. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IS Address
'x.: Permission is hereby ranted to dispose of the human remai s described above as indicated.
::: Date Issued Registrar of Vital Statistics CL.!%(
(signature)
District Number/ Place
1 own of a)) l
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
inDate of Disposition Vail s- Place of Disposition Ehhit.# ,r-
2L (address)
W
U)
CZ (section) A (lot number) r (grave number)
QName of Sexton or Person in Charge of Premises /4c2 r- .)z•vt
Z ( lease print)
LU al Signature Title PenlicrIbit
(over)
DOH-1555(02/2004)