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Truax, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH 73 Vital Records Section Burial - Transit Permit ▪ Name First Middle Last Sex : Evelyn C. Truax Male Date of Death Age If Veteran of U.S. Armed Forces, x.:r November 27, 2014 93 War or Dates iPlace of Death Hospital, Institution or City, Town or Village Johnsburg Street Address Tri-County Nursing Home ii Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Pi Address Death Certificate Filed District Numb r Register Number i':r. City, Town or Village Johnsburg,NY S� 1V ❑Burial Date Cemetery or Crematory Dec 1, 2014 Pine View Crematorium ❑Entombment Address ❑x Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address F Hold N 0 Date Point of O. Transportation Shipment © by Common Destination Carrier I Disinterment Date Cemetery Address I Renterment Date Cemetery Address Permit Issued to Registration Number ::r; Name of Funeral Home Regan Denny Stafford Funeral Home 01443 r : Address .::: 53 Quaker Road, Queensbury, NY 12804 ,.r:. Name of Funeral Firm Making Disposition or to Whom • Remains are Shipped, If Other than Above Address • Permission is ereb gr nted to dispose of the human re ins described bove as i d' ed. oo �'Date Issued �� �O � Registrar of Vital Statistics (signature) District Number Place Johnsburg,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: w Date of Disposition It'i f hi Place of Disposition 411/.....f Cr-,,"(Or 2 (address) W U) Ce (section) (lot numbe (grave number) p• Name of Sexton or Person in Charge o Premises A uvu ' Z (please print) W Signature eir- Title r(z'Nl,iAz.. (over) DOH-1555(02/2004)