Edwards, Jean /o2 t.
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jean Edwards Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/26/2021 80 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Johnsburg Town Street Address Elderwood at North Creek
pManner of Death Natural Cause ❑Accident Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
0 Eric Santell NP
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 48
❑Burial Date Cemetery,Crematory or Facility Name
11/30/2021 Pine View Crematory
ElEntombment Address
ElCremation Queensbury Town,New York
❑Donation
OZ ❑Removal Date Place Removed
and/or and/or Held
- Hold Address
Li
Transportation Date Point of
C 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
1— Remains are Shipped,If Other than Above
2 Address
EC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/29/2021 Registrar of Vital Statistics 7(irt(t(een C.Lorah(E(ectronicaltySigned)
(signature/
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 , q , ^
!L Date of Disposition / .. y Zp2( Place of Disposition �j tJ P 1!J. Cr-'t 47 D-' cs
(address/
W
CD
(section) (lot number) (grave number)
8 Name of Sexton or Person in Ch ge of Premi fq-r et b't`f) 1) b
(please print)
W Signature Title 6 efry s
DOH-1555(07/18)p 1 of 2
I
Public Health Law Sec. 4145(2b) .0 3
Receipt
Human remains of delivered on , 20
Pine View CemeteryRepresenting the funeral home named on burial permit
P g
Official Funeral Directors Reg.or License#