Eisenhardt, Carol NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section ..' 0-- Burial - Transit Permit
Name First Middle Last Sex
::r Carol Ann Eisenhardt Female
0:::: Date of Death Age I If Veteran of U.S. Armed Forces,
July 22,2015 61 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
iii Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
-Circumstances Investigation
Itl
Medical Certifier Name Title
Sean Bain M.D.
fee Address
:: 100 Park Street, Glens Falls,NY 12801
▪,:F: Death Certificate Filed District Number F 0 i Register Number_ev• e
i
Cty, Town or Village W�-'I
❑Burial Date Cemetery or Crematory
July 24, 2015 Pine View Cemetery
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
1- Hold
Cl)
O Date Point of
M.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
..
. Permit Issued to Registration Number
: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
I'�° Remains are Shipped, If Other than Above
Address
.`'HPermission is hereby granted to dispose of the human remains d c ibe a ve 1 , eicated.
• Date Issued 07 Zy/ZO J Registrar of Vital Statistics
(signature)
District Number ��0/ Place 6/p G`3 ,
I certify that the remains of the decedent identified abovee were disposed of in accordance with this permit on:
W Date of Disposition ')-a')—IS Place of Disposition T;rte u:e� Crc,,i*Jet:ti .i
2 (address)
W
CO
W (section) (lot number) (grave number)
ZZ Name of Sexton or Person in Charge of Premises i.tyyd4-4. &ei-ehe
Y (please print)
IliSignature L4., Title Creiic,4®r?, 4S51-•
(over)
DOH-1555(02/2004)