Andrew, Shirley A • # g(a3
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley A.Andrews Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/30/2022 83 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
W
'p Manner of Death ❑X Natural Cause IllAccident ❑Homicide Suicide Undetermined ri Pending
Circumstances Investigation
WMedical Certifier Name Title
G Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury I District Number Register Number
City,Town or Village 15657 162
Burial Date Cemetery,Crematory or Facility Name
11/02/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
t❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
Date Point of
(A nTransportation
Q 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
H Remains are Shipped,If Other than Above
'S Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/01/2022 Registrar of Vital Statistics Caroline Ni gard Bar6er(Ekctronicall:y Signedl)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l— t
Z Date of Disposition )I 13 lZ Place of Disposition
2 (address)
W
(section) ((lot number) (grave number)
8 Name of Sexton or Person in Cha a Premises }^ ,&n,k.x
(please print/
W Signature Title lma��
DOH-1555(07/18)p t of 2
1 372
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#