Herne, Mildred NEW YORK STATE DEPARTMENT OF HEALTH
z2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred Marion Herne F
Date of Death 4/29/2012 Age71 If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
Amy Hogan Moulton MD
Address
Broad Street Glens Falls, NY 12801
Death Certificate Filed District Nn er Registe Nuumber
City, Town or Village Glens Falls Ck.AOoft
El Burial Date Cemetery or Crematory
❑Entombment Pine View Crematorium
Address
®Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
H Hold
N
0 Date Point of
fri❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
j ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
:5 Quaker Road Queensbury NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
W
Permission is hereby granted to dispose of the human remains de ribe ab e icated.
Date Issued (, �j//,Zp/Z- Registrar of Vital Statistics �
(signature)
District Number 17 f Place 4, XI/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition SiI r11, Place of Disposition �J CO-vtar��
(address)
N
CC (section) (lot number) (grave number)
Name of Sexton or Person in Char e of Premises Je",-tist
2 / ((please print)
ILI
Signature t Title CCt24)1 0
(over)
DOH-1555 (02/2004)