Bradway, Louella J Z2y
NEW YORK STATE DEPARTMENT OF HEALTH . It
Vital Records Section Burial - Transit Permit
oc Name First Middle Last Sex
f Louella M. Bradway Female
Date of Death Age If Veteran of U.S. Armed Forces,
r: March 23,2015 88 War or Dates
I�jrr Place of Death Hospital, Institution or
�' City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
Manner of Death
X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
; Daniel Larson
r Address
;. s 9 Carey Road,Queeensbury,NY 12804
r Death Certificate Filed District Number Register mber
City, Town or Village Fort Edward 5755 p7
❑Burial Date Cemetery or Crematory
March 25, 2015 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
Cl)
0 Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
$:r:; Permit Issued to Registration Number
:44rrr Name of Funeral Home Regan Denny Stafford Funeral Home 01443
fj, Address
i : 53 Quaker Road, Queensbury, NY 12804
4Name of Funeral Firm Making Disposition or to Whom
':" Remains are Shipped, If Other than Above
Address
;r; Permission is ereb granted to dispose of the huma ins described ove indicated.
;f;; Date Issued Registrar of Vital Statistic (
;};•X (signature
::;� District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition3 (C Place of Disposition �i?/rt J%#C4,.,! alsee!,/,'
W (address)
N
W (section) /lot number) (grave number)
gName of Sexton or ers i harge of Premises � � (iL Lwot 7n-1 d
Z (please pri t)
W Signature 1 d Title - ?, 1. � i,
(over)
DOH-1555(02/2004)