Boerem, Traci NEW YORK STATE DEPARTMENT OF HEALTH `\\, \ - J c
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Traci L. Boerem Female
"- Date of Death Age If Veteran of U.S. Armed Forces,
January 1, 2012 42 War or Dates
. Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 4 Greenway Dr
O Manner of Death Natural Cause Accident Homicide Suicide Undetermined x Pending
:W Circumstances Investigation
W Medical Certifier Name Title
pf Timothy Murphy Coroner
Address
52 Haviland Rd.,Queensbury,NY 12801
Death Certificate Filed Dist jcL m eciber i R er Number
c
City, Town or Village Queensbury �� J
❑Burial Date Cemetery or Crematory
January 6, 2012 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
co
O Date Point of
O.
• Transportation Shipment
p by Common Destination
Carrier
Disinterment Date ' Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i.- Remains are Shipped, If Other than Above
;Z Address
:W
a Permission is ereby granted to dispose of the human re ains described above as indicated.
Date Issued 1 S lo2.0 0 Registrar of Vital Statistics G
.._ ..._
(signature)
District Number ao c "7 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1-9- i t Place of Disposition ,R4) o Corn-4-1 ori,,t,.
W (address)
U)
Ce (section) /11 (lot number) r (grave number)
Q Name of Sexton or Person in Charge Premises L br,kt lrr 3eh..ill-
Z (please print)
W /�
Signature G Title CII rnlytcd,
i
(over)
DOH-1555(02/2004)