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Merzig, Christine NEW YORK STATE DEPARTMENT OF HEALLH NEW Vital Records Section Burial - Transit Permit Name First Middle Last Sex Christine A Merzig Female Date of Death Age If Veteran of U.S. Armed Forces, ', October 18, 2013 56 War or Dates Place of Death Hospital, Institution or City, Town or Village Queensbury Street Address 5 Mohawk Trail Manner of Death C Natural Cause Accident n Homicide n Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title f Donald Merrihew MD {`a Address <: 319 Bay Rd.Queensbury NY 12804 Death Certificate Filed District Number Register Number ,�, City, Town or Village Queensbury 5657 0 ❑Burial Date Cemetery or Crematory ❑Entombment October 21,2013 Pine View Crematorium Address ©Cremation 21 Quaker Road, Queensbury,NY 12804 Date Place Removed OZ n Removal and/or Held and/or Address N Hold 0 Date Point of u)a. U Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address [7 Reinterment Date Cemetery Address , Permit Issued to Registration Number L Name of Funeral Home Regan Denny Stafford Funeral Home 01443 F{ Address rr, 53 Quaker Road, Queensbury,NY 12804 f Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address • } Permission is hereby granted to dispose of the hum n remains described above as indicated. Date issued I O ! IRegistrar of Vital Statistics Cam-`__C { � (signature) .:?':4 District Number Place 5657 Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition /p(jzID Place of Disposition rr''114 C LLI (address) N re (section) (!ot umber Q (grave number) ZName of Sexton or Person in Charge of Pre ises r,j1 .h41 tu Z (pf ase print) Signature liL Title CIj,&r 9 (over) DOH-1555(02/2004)