Delvaux, Mary , . -I # t3
NEW YORK STATE DEPARTMENT OF HEALTH t Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary E. Delvaux Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 4, 2015 56 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 250 Lamplighter Acres
1 Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
1Medical Certifier Name Title
Mark M.Doyle
rr 3 Address
• 135 North Road,Wilton,NY 12831
iiiii Death Certificate Filed District Number Register Number
City, Town or Village Moreau 4562
•• ❑Burial Date Cemetery or Crematory
June 8, 2015 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
! Hold
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O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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
I• '; Remains are Shipped, If Other than Above
• Address
:;r Permission is hereby granted to dispose of the human rem • s describ ab ve as indicated.
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Date Issued 062/03/20/S Registrar of Vital Statistics �,{,�,ty(
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s: District Number Place Moreau,NY /Z,$Zi
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• 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 1°1tIr Place of Disposition ....• (10.--'tote►.
2 (address)
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O (section) A •- (lot number (grave number)
QName of Sexton or Person in Charge of Premises �,V �twdil
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Signature /►/�� Title t"itfo►l9/1_
(over)
DOH-1555(02/2004)