Bull, Madeline t
T 1
A -120
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
:K. Name First Middle Last Sex
Madeline Elaine Bull Female
0: Date of Death Age If Veteran of U.S. Armed Forces,
r:;; September 27,2015 88 War or Dates NA
v.: Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
I/ Circumstances Investigation
Medical Certifier Name Title
el leery Spinet ,4 � �
Address n1 Cal-P_y y\ 7 e RS b C -/ t �' 120-1?�; r Death Certificate Filed ` D$oie
ct Number Register!lumber
.; City, Town or Village Fort Edward Eel.5
❑Burial Date Cemetery or Crematory
II Entombment October 1, 2015 Pine View _ LT"2 rYl(3, -�,ry
Address
L1 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
pi I I Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
:f Permit Issued to Registration Number
;tip; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
;tip Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
0 Permission is ereb granted to dispose of the human inssdescr'be b ve s indicated.
Date Issued q aq 1 Registrar of Vital Statistics V`
M (signature)
r. District Number �51 55 Place I 610-K 6-6 f—tue aLLOCOCA
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 10/t I ic' Place of Disposition ,,uU,.,, e acu n--
W (address)
CO
p0 (section) (lot numbed() (grave number)
��7 Name of Sexton or Person in Charg of Premises lit;IS— 31M '
WI
(please print)
Signature Lam` Title tht
(over)
DOH-1555(02/2004)