Ahrens, Dayle R 2ig
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Dayle R Ahrens Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/17/2022 78 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address 331 East Road,Fort Edward Town,New York 12828
p Manner of Death Natural Cause Accident El HomicideSuicide Undetermined ❑Pending
W Circumstances Investigation
WMedical Certifier Name Title
Curtis Gedney MD
Address
454 Glen Street,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 26
Burial Date Cemetery,Crematory or Facility Name
03/18/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
• Hold Address
to Trans ortation Date Point of
p Shipment
Q by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I. Remains are Shipped,If Other than Above
• Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/18/2022 Registrar of Vital Statistics Aimee L Mahoney(ElectronicatTy 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: _
Z
▪ Date of Disposition ./g ZO2L. Place of Disposition rl ,-JL 0 .vt/pp C't t, /YJ/`
2 (address)
W
(n (section) (lotyumber (grave Name of Sexton or Person in Char of Premises number)
Q (<'/44149,a /44/
O
Z /, (please print)
W Signature /Y Title dp�a
DOH-1555(07/18)p t of 2
d n
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#