Molner, Irene f It 761
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First
.:0:: Middle Last Sex
tip_ Irene E. Molner Female
;;:: Date of Death Age If Veteran of U.S. Armed Forces,
▪. December 7, 2014 91 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
aManner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Eileen Spinelli MD
r:tir
Address
:ra 9 Carey Rd,Queensbury,NY 12804
:ti? Death Certificate Filed District Number Regist%Number
•x. City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
December 10, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
(4
0 Date Point of
yTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
j ; Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
ti Address
: 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 r Remains are Shipped, If Other than Above
Address
v.
E::::: Permission is hereby ranted to dispose of the human re ains described above as indicated.
.r 3 Date Issued Registrar of Vital Statistics I , &OYU V 0 /LP--4±L tf----,
:: 7 / (signature)
::i:: District Number 5755 Place Fort Edward
I certify that the remains of thedecedent identified above w disposed of in accordance with this permit on:
WDate of Disposition -/ Place of Disposition t/1)4 /
2 � t
W (address)
CO
O (section) Of numbe0 (grave number)
p Name of Sext r P r n i Charg of Premises 0.1) WW1-C--
Z ^ (please print)
LU (�` t, �,�,/.���v
Signatur Title
J
(over)
DOH-1555(02/2004)