Warden, Irene 11 NEW YORK STATE DEPARTMENT OF HEAI TH -� 41 Z j
Vital Records Section Burial - Transit Permit
`' Name First Middle Last Sex
;g; Irene Margaret Warden Female
Date of Death Age If Veteran of U.S. Armed Forces,
} ' April 11, 2013 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Pines At Glens Falls
1Manner of Death X Natural Cause Accident Homicide pi Suicide n Undetermined Pending
;r
Circumstances Investigation
w Medical Certifier Name Title
Suzanne M.Rayeski,MD
Address
170 Warren Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 r 5-
0 Burial Date Cemetery or Crematory
April 15, 2013 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation 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
, '. Remains are Shipped, If Other than Above
Address
l
.: Permission is hereby granted to dispose of the human remains described above as indicated.
f
Date Issued /t 51 / 3 Registrar of Vital Statistics i"-1 ,1,J
(signatu
X%'f'f=
>< District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed
elk,/
of in accordance with this permit on:
W Date of Disposition 1-Ib-tom Place of Disposition 644-40ti,—
W (address)
U)
te (section) �� (lot number)( (grave number)
Q Name of Sexton or Person in Charge of Premises r:I giudt
Z please print)
W71.Signature 19_._ 2.-- Title Cir7416 r}zir)C
(over)
DOH-1555(02/2004)