Hall, Euphcmia 07-10-12;07: .364M; ; 518 644 2476
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
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Name First Middle Last Sex
Euphemia K Hall Female
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•.:.': Date of Death Age If Veteran of U.S.Armed Forces,
July 6, 2012 86 War or Dates
"g Place of Death Hospital, Institution or
Z City, Town or Village Blolton Landing Street Address 5 Maple Street
MI
a Manner of Death
I 11- Natural Cause E Accident Homicide 7 Suicide Undetermined Pending E
w Circumstances Investigation
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w Medical Certifier Name Title
Per2--,1 ,,.
. AtItT7e.sLe 8
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•••: Death Certificate Filed 7
1.•• District Number Register Ny,ber
City.Town or Village Bolton Landing 5tv50
I:Burial Date Cemetery or Crematory
July_lig 2012 Pine View Crematorium
D entombment
Address
NI Cremation 21 Quaker Road,gtieensbury,NY 12804
Date Place Removed
Z ri Removal and/or Held
2 and/or Address - -
r" Hold
-
073— Date Point of
011 L—ji Transportation - Shipment
3 by Common Destination
Carrier
-
_
E Disinterment Date Cemetery Address
Date Cemetery Address
r i Reinterment ,
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Stafford Funeral Home 01443
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7:7.: Address
53 Quaker Road,Quecnsbury,NY 12804
*7: Name of Funeral Firm Making Disposition or to Whom
g Remains are Shipped, If Other than Above
2 Address
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Permission is hereby granted to dispose of the human rma.ijs described above as indicated. __
:•:.:
Date Issued 17- 10-/P- Registrar of Vital Statistics A -Ia.& St4029,
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(signature)
District Number 56 ,TO Place Bolton Landing
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Lu Date of Disposition -HO- It Place of Disposition efra ,./ Croi-ctOr IL.,...
2 (address)
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Ce (section) i (lot number) c. (grave number)
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0 Name of Sexton or Person in Ch rge of Premises raiVir r- Jiviwett
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____ pease print)
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Signature Title CP-ttm pri704_,_
(over)
DOH-1555(02/2004)