Ackley, Edna NEW YORK STATE DEPARTMENT OF HEALTH y I 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edna M. Ackley Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 29,2013 102 War or Dates
I.„ Place of Death Hospital, Institution or
Z City,Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
p Manner of Death Q Natural Cause El Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
G Daniel Larson MD
Address
9 Carey Road,Queeensbury,NY 12804
Death Certificate Filed District Number Register ber
City, Town or Village Town of Fort Edward v 213 1
❑Burial Date Cemetery or Crematory
ugust 30, 2013 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z E1Removal and/or Held
and/or Address
E Hold
O Date Point of
co Li Transportation Shipment
• by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment 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
H Remains are Shipped, If Other than Above
2G Address
a Permission is ere y granted to dispose of the human remai describ above as indicated.
Date Issued Registrar of Vital Statis cs GCaQ�
(signature)
District Number �' Place Town of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 11513 Place of Disposition Ze011.4 . ..
111
(address)
(section) A ( number �1 (grave number)
QName of Sexton or Person ' Charge Premises {ae„+�K/
Z print
W Signature ( Title ci2pMtyTC
(over)
DOH-1555(02/2004)