Harrison, Edna NEW YORK STATE DEPARTMENT OF HEALTH 9 41 2 3
Vital Records Section Burial - Transit Permit
Name First Middl Last Sex
''' Edna (_. Harrison Female
, Date of Death Age If Veteran of U.S. Armed Forces,
A s ril 16, 2013 10 t War or Dates
Place of Death Hospital, Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death yl Natural Cause Accident Homicide 'Suicide Undetermined Pending
VI Circumstances Investigation
Medical Certifier Name��q ) Title M
N
Address
c D ey .� t 21 fE- lQy �..
0Death Certificate Filed L District Numbe5601 l Register Number
, City,Town or Village Glens Falls /40 d
❑Burial Date Cemetery or Crematply
❑Entombment Address '
N Cremation Zj!j g Q y
Date Place Removed
Z I I Removal and/or Held
0 and/or Address
F- Hold
CO
o Date Point of
n Transportation Shipment
a by Common Destination
Carrier
n Disinterment
Date Cemetery Address
n Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Re Ian Denn Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
}fr.
Name of Funeral Firm Making Disposition or to Whom
f Remains are Shipped, If Other than Above
Address
rl
trri
fr.,
Permission is ere y granted to dispose of the huma emains descr'bed able as indic. ed.
Date Issued O'f �� 0�20 Registrar of Vital Statistics / r
(signature)
r District Number 5601 Place Glens Falls f4/ lP2
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11.1 Date of Disposition Li- Pt-t3 Place of Disposition ?et IL/ C.i.c.iun a-._
(address)
W
re (section) // (lot number) ` (grave number)
QName of Sexton or Person in Charge f Premises ` r^3Z � Qrst t-
( ease print)
ut
Signature Title Cd P)11Ta-
(over)
DOH-1555(02/2004)