Humphrey, Aretha May zp
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Aretha May Humphrey Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/13/2022 97 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
W▪ Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Carrie Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 25
Burial Date Cemetery,Crematory or Facility Name
MEM 03/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
I Hold Address
N
0 Date Point of
(I)❑Transportation Shipment
G by Common
Carrier Destination
El
Disinterment
Date Cemetery Address
El 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
a Address
ft
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/16/2022 Registrar of Vital Statistics Aimee L Mahoney(E(ectronica1Ty Signed)
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
I▪ Date of Disposition 3ItV I ZZ Place of Disposition at 40----(a Tess)
W
CO
CC (section) (lot number) < (grave number)
Q Name of Sexton or Person in Charge of Premises 0 �, .3Grrn it
z O (pie+print) F��Mw�e
W Signature 6 Title ` IL
DOH-1555(07/18)p 1 of 2
r
Public Health Law Sec. 4145(2b)
Receipt
i Human remains of - delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#