Choate, Virginia 1143
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
E::: Name First Middle Last Sex
Virginia Marie Choate Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 9, 2012 81 War or Dates
%k': Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
a Manner of Death 71 Natural Cause Accident Homicide n Suicide Undetermined Pending
aiSj Circumstances Investigation
us' Medical Certifier Name ,� 71-/ �5� � itle
P. u
Address
1 0Abh1A\ti EOP-1 .D1/6142b, rJy (ZSL`a
:Yv Death Certificate Filed Distris,t� ber Regis r Number
City, Town or Village Fort Edward j
❑Burial Date Cemetery or Crematory
March 12, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
Q Date Point of
u) Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
-:i 53 Quaker Road, Queensbury,NY 12804
p Name of Funeral Firm Making Disposition or to Whom
IN+ Remains are Shipped, If Other than Above
S Address
g.
:::,j Permission is h reb granted to dispose of the human a;ns described bov s indicated.
Date Issu d Registrar of Vital Statisti
(signature
%:,:1 District Number 1-12 ,3 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 311H 1cz, Place of Disposition -ea LA-) Ctwitorte
2 (address)
W
CA
(section) �i - (lot number) - (grave number)
pName of Sexton or Person in Charge of Premises `hr;s "v ' J/,,,ifF-
Z 1 (please print)
W
Signature ,i� Title COVi 4-Tdi_
(over)
DOH-1555(02/2004)