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O'Brien, Elizabeth M NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Elizabeth M O'Brien Female Date of Death Age If Veteran of U.S.Armed Forces, 08/25/2021 76 Years War or Dates 1_, Place of Death Hospital,Institution or WCity,Town or Village Albany Street Address Albany Medical Center Hospital Ci Manner of Death ©Natural Cause Accident ❑Homicide I=1 Suicide ❑Undetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title C Wesley Henze Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed District Number Register Number City,Town or Village Albany 0101 2110 ©Burial Date Cemetery,Crematory or Facility Name 09/01/2021 Pine View Cemetery ElEntombment Address ElCremation Queensbury Town,New York ElDonation Date Place Removed ❑Removal and/or Held F and/or N Hold Address 0 • Date Point of Cl) ❑Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ElDisinterment 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 i` Remains are Shipped,If Other than Above 2 Address Cr W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 08/27/2021 Registrar of Vital Statistics Danierk S C i(Cespie(ECectronicatry Signed) (signature) District Number 0101 Place Albany, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- Z Date of Disposition 9/1 /2021 Place of Disposition 21 Quaker Rd Queensbury, NY 12804 W (address) N Erie 79G 2 cc (section) (lot number) (grave number) 8 Connie Goedert Name of Sexton or P rson in Charge of P mises (please print) W Signature -6/246' g .oce Title Superintendent DOH-1555(07/18)p 1 of 2 I Public Health Law Sec. 4145(2b) 012870 Receipt Human remains of' delivered om.: , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# O'Brien NAME Elizabeth M. O'Brien Age: 76 LotOwner: J. Davis O'Brien Lot# Erie 79 G Grave# 2 Case: Concrete Died: 8/25/2021 Interred: 9/1 /2021 Funeral Home: Regan Denny Stafford Cemetery: Pine View