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Myers, Georgiana Marie NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Georgiana Marie Myers Female Date of Death Age If Veteran of U.S.Armed Forces, 11/08/2021 76 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 125 Mountain View Lane,Queensbury Town,New York 12804 'p Manner of Death ©Natural Cause ElAccident ❑Homicide ❑Suicide Undetermined El Pending Circumstances Investigation W Medical Certifier Name Title CI Gerard Abess MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 218 ©Burial Date Cemetery,Crematory or Facility Name 11/17/2021 Pine View Cemetery ❑Entombment Address ❑Cremation Queensbury Town,New York ❑Donation 0❑Removal Date Place Removed and/or and/or Held H Hold Address (0 Transportation Date Point of ❑ S by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑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 2 Address Q W EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2021 Registrar of Vital Statistics Caroline x&egarie Barber(ECectronicalty Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— W Date of Disposition 11 /17/2021 Place ofDisposition 21 Quaker RD. Queensbury, NY 12804 2 (address) ui Mohawk 56 2 Q (section) (lot number) (grave number) 8 Name of Sexto Person in Char gg e#Premises Connie Goedert z C 9 (please print) W Si nature _.©tit2 ��v1 Title Superintendent s DOH-1555(07/18)p 1 of 2 1 Public Health Law Sec. 4145(2b) 1287 9 1 Receipt / I , i 1 Human remains of . /- / ,..i.,i_i delivered on -A /' / A , 20 ::-./ I Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# •- ' MYERS (L ) NAME Georgiana Myers Age: 76 Lot Owner: Georgiana Myers Lot# Mohawk 56 Grave# 2 Case: Concrete Died: 1 1 /8/21 Interred: 1 1 /1 7/21 Funeral Home: Regan Denny Stafford Cemetery: Pine View MYERS (1.7.I Lot No. jg Address Mountain View Lane Glens Falls, vew York 12801 Section No. Owner Georgiana Myers Plot Mohawk Date 12/12/84 Arprox. 133 Superficial ft. @ Location Bounded on the North by Vacant & Hodge, on the South by Vacant, on the past by • Gordon & Streeter, on the West by Vacant. Corner Posts Remarks Deed No. (and changes) 1889 Payment Record 10/23/84 — 1 grave purchased 12/12/84 — 3 additional graves purchased Record of Interments V C-cx-r)r 1 2 ter-,mac '►c4nr, m.�er \1- �7 a ►- -at w 1 ,Fti4ku.„,_..„._. ,,- . N, ,,, , , , „, , rs 3 y cam �= $ 1 s- 1 /fir 7 --S � lY L ' 1 Form No. 01 ;-0 ti'c/b► ; 4- >y"G e rt e V