Madison, Sherry A NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last
Sherry A Madison Sex
Date of Death Female
Age I If Veteran of U.S.Armed Forces,
08/21/2022 85 Years Waror Dates
Place of Death Hospital,Institution or
Z QueensburyCity,Town or Village Town I Street Address 17 Pinewood Avenue,Queensbury Town,New York 12804
W Man nerof Death ElNaturalCause DAccidentID Homicide ❑ ❑Suicide Undetermined ❑Pending
U Circumstances Investigation
WW Medical Certifier Name Title
Anthony Petracca MD
Address
3 lrongate Center,Glens Falls,New York 12801
Death Certificate Filed Town aQueensbury District Number Register Number
5Cit ,Town or Village
5657 121
Burial Date Cemetery,Crematory or Facility Name
08/26/2022 Plneview Cemetery
Entombment Address
❑Cremation Queensbury Town,New York
DDon atio n
0 Removal Date Place Removed
F . and/or and/or Held
N Hold Address
O
d Date Point of
N❑Transportation
G by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
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
S Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/23/2022 Registrar of Vital Statistics Carotme.7!tagar4 As is,'(*F.Gcttvnicvil;Srgnsd)
(signature)
Utslric1►eumder 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: \_
WDate of Disposition p. aa, Place of Disposition n71 ill ,Gy eR q0 t" o Ae.ec 3'c 1 ry i a8'N�1
// (address) I
ill TUR/CciV Al i
Si
t (section/ /' (lot number) (grave number)
S Name of 5ext r Person in Cha es nr)j d R
(please print)
Z f(ALL
St�nalure Title �� 1�1''b'n� r
DOH 1555 WW1 1plof2
Public Health Law Sec. 4145(2b) 012933
Receipt
i
IHuman remains of Ski<g , ,i , delivered on -7, • , 20iLl..
11 ,,r/1,41.., , K.- --T•
,
line View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
MADISON
NAME Sherry A. Madison Age: 85
Lot Owner: Thomas Madison
Lot# Horicon 41D Grave# 2
Case: Concrete
Died: 8.21 .22 Interred: 8.2 6.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View