Conklin, Teri NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
:(7,1 Name First Middle Last Sex
{ Teri Lee Conklin Female
tt{
Date of Death Age If Veteran of U.S. Armed Forces,
1$ September 16, 2015 71 War or Dates n/a
'';;J Place of Death Hospital, Institution or
City, Town or Village Fort Edward, NY Street Address Fort Hudson Nursing Home
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
" Dr Daniel Larson,MD
Address
Queensbury,NY
;:;
> Death Certificate Filed District Number Register Number
l City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
September 17, 2015 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
!_ Hold
CO
O Date Point of
N ['Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
3;1, Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i' Address
fir: 53 Quaker Road,Queensbury, NY 12804
''J?f Name of Funeral Firm Making Disposition or to Whom
'' Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the hu ns descrbed b e s indicated.
! Date Issued q-(,"15 Registrar of Vital Statistic ‘
1 (signature)
fl District Number 5155 Place-nrsityik. 0.6 ea(A)CIA-CI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition g/16116 Place of Disposition 24SL Cri orw-s
W (address)
CO
re (section) /I lot number) (grave number)
pName of Sexton or Person in Charge of Premises `A',Jr •�
`Z4 (please print)
Signature % Title ll'PShiP/M,.
(over)
DOH-1555(02/2004)