Monroe, Eileen NEW YORK STATE DEPARTMENT OF HEALTH 56`
Vital Records Section Burial - Transit Pbrmit
.
Name First Middle Last Sex
Eileen F. Monroe Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 24,2013 59 1 War or Dates
1,., Place of Death Hospital, Institution or
z City, Town or Village Queensbury Street Address 13 Oak Tree Circle
W.
Manner of Death n Natural Cause C Accident 0 Homicide [1 Suicide Undetermined �Pending.14 rt
Circumstances Investigation
M. Medical Certifier Name Title
a Timothy Murphy
Address
52 Haviland Ave,Queensbury,NY 12804
Death Certificate Filed District Number Re ester Number
City, Town or Village Queensbury 5657 -6`3
❑Burial Date Cemetery or Crematory
❑Entombment Pine View Crematory
Address
®Cremation Quaker Road, Queeensbury,NY
Date Place Removed
z C Removal and/or Held
0 and/or Address
H Hold
N
0 Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
i I 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
Permission is hereb granted to dispose of the human re a'ns described abov as indicated.
,
Date issued 1 Registrar of Vital Statistics q , c ry n..,___
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 6-jg-(3 Place of Disposition , E L1L1 (,vr—,
us (address)
fn
0 (section
) ( t number � (grave number)
Name of Sexton or Person in Charge of P emises r=it
2
W ll please print)
Signature 4
l� Title GUI y
(over)
DOH-1555(02/2004)