Zacharias, Agnes NEW YORK STATE DEPARTMENT OF HEALTH
Burial - Transi Permit
Vital Records Section
',: Name First Middle Last Sex
Agnes Anna Zacharias Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 18, 2012 94 War or Dates
; ; Place of Death Hospital, Institution or
.Z: City, Town or Village Schuylerville Street Address Stanton Nursing & Rehab Centre
Ai-Manner of Death Undetermined Pending
tip' X Natural Cause n Accident n Homicide ]Suicide
Lii Circumstances Investigation
us. Medical Certifier Name Title
P. Roslyn Socolof MD
Address
152 Sherman Ave. Queensbury,NY 12804
: Death Certificate Filed District Number Regis er Number
°-3e City, Town or Village Queensbury NY-054321 1
❑Burial Date Cemetery or Crematory
January 23, 2012 Pine View Crematory _
❑Entombment Address
Ex Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
F' Hold
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O Date Point of
N I !Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
: Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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Fkn Permission is hereby granted to dispose of the human remains describednn bpve as indicated.
Date Issued 1 / �6,Q la,Registrar of Vital Statistics G� �-�1 •, ( fu..—__
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(signature)
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District Number NY-054321 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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W Date of Disposition (/2 y Ai_ Place V Place of Disposition „ Caw ciu(Ste.
W (address)
co
O (section) r (lot number) (grave number)
pName of Sexton or Perso in Charge of Premises I I t,s ...At
Z (please print)
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Signature Title Ctzn n'►1'tiditi
(over)
DOH-1555(02/2004)