Kerr, Mary OW
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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
s:?:; Name First Middle Last Sex
``:' Mary A. Kerr Female
rfL' Date of Death Age If Veteran of U.S. Armed Forces,
;' December 14,2015 93 War or Dates
IPlace of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death X Natural Cause 1 I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
1 Medical Certifier Name Title
::R. Roselyn Scolof,MD
r`• Address
ti
: 42 Gurney Lane,Queensbury,NY 12804
a`: Death Certificate Filed District Number Rggi$te�r Number
4s; City, Town or Village Town Of Queensbury 5657 s3
❑Burial Date Cemetery or Crematory
12/16/2015 Pine View Crematory
❑Entombment Address
CI Cremation Queensbury,NY !1.OL'
Date Place Removed
Z Removal and/or Held
O and/or Address
F" Hold
Cl)
0 Date Point of
Nl i Transportation 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
:': Address
ii
ias 53 Quaker Road, Queensbury,NY 12804
:e: Name of Funeral Firm Making Disposition or to Whom
,i4, Remains are Shipped, If Other than Above
Address
` Permission is hereby gran-teed to dispose of the human remains described move as indicated.
': : Date Issued )41Ck la0/`� Registrar of Vital Statistics tc_ Q �_ A_A �,
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(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition j Z_/7./5 Place of Disposition P,hQ0f C,fgryl j2,ly
2 (address)/
W
U)
Ce (section) (lot number) (grave number)
Q Name of Sexton o Pe on in Charge of Premises 3 I ia-A K4,1,2
Z (please print)
111
Signature Title .0 rery41Bfy 4.Ss/3-4.
(over)
DOH-1555(02/2004)