Liechti, Liselotter E. •
i3 2-1
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Liselotte E.Liechti Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/18/2020 90 Years War or Dates
1.. Place of Death Hospital,Institution or
WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
Q Manner of Death ❑X Natural Cause ❑Accident 0 Homicide ❑Suicide ❑Undetermined 0 Pending
ILI
0 Circumstances Investigation
g Medical Certifier Name Title
Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 109
❑Burial Date Cemetery,Crematory or Facility Name
12/21/2020 Pine View Crematory
❑Entombment Address
gCremation Queensbury,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
F- Hold Address
(l) ❑Transportation Date Point of
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
12 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
° Remains are Shipped,If Other than Above
3 Address
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ri Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/21/2020 Registrar of Vital Statistics Aineegfalroney(Ekctronicall:ySlgned)
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t
W Date of Disposition 12-2z.70ze Place of Disposition PiY!(ZU!� (j/r�,yl
a (address)1
W
i (section) t (lot number) (grave number)
SName of Sexton or Perso ' Cha f Premises NJ tvii Ct v1 64,1,0 Lc.( I-
Z (please print) �/
W Signature G Title lileZL.'U� e
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b) - M 0143.11
Receipt
z
Human remains of 'delivered on , 20
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e View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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