Flynn, Virginia NEW YORK STATE DEPARTMENT OF HEALTH f ? 286
Vital Records Section I Burial - Transit Permit
• Name First Middle Last Sex
Virginia Mae Flynn Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 1, 2012 93 War or Dates
iPlace of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
a° Manner of Death rr Natural Cause n Accident n Homicide Suicide Undetermined Pending
US Circumstances Investigation
%j Medical Certifier Name Title
A SP ' A-, SLDD.I0r3t MP'.
I.
Address
Death Certificate Filed District Number Register Number
City, Town or Village Fort Edward -"T" """''"5
❑Burial Date Cemetery or Crematory
El Entombment June 4, 2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ H Removal and/or Held
and/or Address
Hold
N
O Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
7 Disinterment Date Cemetery Address
n 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
F Remains are Shipped, If Other than Above
E; Address
°
` Permission is he e granted to dispose of the human r 'ns described above as ndicated.
Date Issue / JJ— Registrar of Vital Statistics L/ —Z..4.
(signature)
District Numbe,7,5� Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z (�
ILI Date of Disposition (,(E4(4'._. Place of Disposition .. Vito rirre'1'orw�
2 (address)
W
Cl)
tY (section) - (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Iris 4%r4
Z (please print)
IllSignature Title ( FJ -'1o2
(over)
DOH-1555(02/2004)