Farrell, Mary 4 . it # 313
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
- Name First Middle Last Sex
Mary L. Farrell Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 12,2012 90 War or Dates
yam' Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls, Street Address The Pines Of Glens Falls
y Manner of Death U Natural Cause Accident Homicide Suicide n Undetermined Pending
US Circumstances Investigation
� Medical Certifier Name Title
ef Maureen Hyland
Address
9 Carey Road Queensbury, NY 12804
• R Death Certificate Filed District Numbe5601 Regisrt.imlper
i City, Town or Village Glens Falls ��"It
❑Burial Date Cemetery or Crematory
June 18,2012 Pine View Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
yI I Transportation Shipment
a by Common Destination
Carrier
Date Cemetery Address
ri Disinterment
n Reinterment
Date Cemetery Address
-r1- Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01444
Address
- 94 Saratoga Avenue, South Glens Falls,NY 12803
• Name of Funeral Firm Making Disposition or to Whom
144 Remains are Shipped, If Other than Above
,E Address
7 Permission is hereby granted to dispose of the human remains described/aJbove s indicated.
• Date Issued 06 lY Z!7/L �'Registrar of Vital Statistics iI GC -�r�.
/ (signature)
: District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z U Cf'w'r l
•
� Date of Disposition Gill �2 Place of Disposition „� uv eflJti
(address)
W
Cl)
OC (section) A� - (lot number)c (grave number)
ap `Name of Sexton or Person in Charg of Premises tI,y'ttf" JetiviF
Z IL
(olease print)
W Signature � Title C1 MI-T0 -
(over)
DOH-1555(02/2004)