Eggelston, Edwin . ..... L., # ifli
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edwin J Eggelston Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 30,2015 93 War or Dates
Place of Death Village BallstonHospital, Institution or
a Spa City, Town or Village g Street Address Ellis Hospital Schenectady NY
Manner of Death r71
iyi Natural Cause 0 Accident 0 Homicide D Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
CStephen Strader MD MD
Address
61 Rowland St Ballston Spa NY 12020
I,, Death Certificate Filed District Number Register Number
City, Town or Village Village Ballston Spa 4520 47
❑Burial Date Cemetery or Crematory
June 02,2015 Plneview Crematory
❑Entombment Address
®Cremation Town of Queensbury
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
Date Point of
th Q Transportation Shipment
4.4 by Common Destination
' " Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 10910
Address
7 Sherman Avenue, Corinth NY 12822
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 human rem ins desc 'bed ab s indicated.
Date Issued June 02, 2015 Registrar of Vital Statistics , (111
(signature)
• District Number 4520 Place Village Ballston Spa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 Date of Disposition 6/1(t( Place of Disposition OJ C
W (address)
(section) � (lot number) (grave number)
Name of Sexton or Person in Charge of Premises G is<l ty.,- d��niu
e print)
Signature (pl eds Title tIat
(over)
DOH-1555(02/2004)