Irvine, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Ann Irviine Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 22, 2014 85 War or Dates
Place of Death Hospital, Institutiorindiian River Rehab & Health Care
, City, Town or Village Granville Street Address Center. Inc.
Manner of Death X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
gi' Sean Bain
Address
0100 Park St,Glens Falls,NY 12801
, Death Certificate Filed District Number Register Number
€: ', City, Town or Village Village of Granville 5725 Q9
❑Burial Date Cemetery or Crematory
El Entombment September 24, 2014 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I I Removal _ and/or Held
and/or Address
H Hold
CO
0 Date Point of
yTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
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
14; Remains are Shipped, If Other than Above
IAddress
Permission is hereb granted to dispose of the human remain- • - - • - •i ve as indicated.
Date Issued '11Z3 flit Registrar of Vital Statistics e , _gi.l.
(signature)
District Number 5725 Place Village of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition aIz'Iw Place of Disposition 111EiL, (r --
2 (address)
W
U)
tY (section) (lot number) — (grave number)
O
p Name of Sexton or Person in Charge of Premises ti'+` rr iked
Z (p/e a print)
tu Signaturetilt— 2. Title atiE111111,
(over)
DOH-1555(02/2004)