Shaffer, Marie • ._ l• it 15'j
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•r Name First Middle Last Sex
Marie L. Shaffer Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 5, 2014 69 War or Dates
'"':ti Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
ti Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
A Phillip J.Gara Dr.
Address
327 Broadway,Fort Edward,NY 12828
Death Certificate Filed District Number Regis 'lumber
. City, Town or Village Fort Edward 5755 '�pp
❑Burial Date Cemetery or Crematory
III Entombment k a I O k idti 4 Pine View Crematorium
Address
E1 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
Cl)
0 Date Point of
a.
N Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
IReinterment Date Cemetery Address
Iii Permit Issued to Registration Number
i§ii Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
R: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
i:
Address
ti : Permission is hereby granted to dispose of the hum n ains described o ,e s indicated.
+�•: lJ r, ,� >�
::::: Date Issued ��Q it-( Registrar of Vital Statistics ! `�-1-�1� i �
(signature)
District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition RLHINNN Place of Disposition a Cr+4t:..r
W (address)
(I)
Ce
(section) (lot num ) (grave number)
QName of Sexton or Person in Charge of Premises /�r .. '
Z J(please print)
W Signature Title Ctuzminl,
(over)
DOH-1555(02/2004) -