Lebowitz, Henrietta NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Henrietta B. " Lebowitz Female
Date of Death Age If Veteran of U.S.Armed Forces,
F February 28, 2006 84 War or Dates
2 Place of Death Hospital, Institution or
W City,Town,or Village Fort Edward Street Address Fort Hudson Nursing Home
0 Manner of Death X XJatural Cause n Accident n Homicide 111Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
0 Medical Certifier Name Title
W Daniel Larson, MD
Q Address
Glens Falls, NY
Death Certificate Filed District Number Regist tuber
City,Town or Village Fort Edward �'�75
0 Burial Date Cemetery or Crematory
Shaaray Tefila
❑Entombment Address
❑Cremation Queensbury, NY 12804-
2
Date Place Removed
0 Removal and/or Held
and/or Address
i' Hold
Y) Date Point of
0 0 Transportation Shipment
L by Common Destination
0 Carrier
Date Cemetery Address
a 0
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan & Potter Funeral Home 01734
Address
407 Bay Road, Queensbury, New York 12804
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is h re y granted to dispose of the human re ins described abov as indicated.
Date Issued Registrar of Vital Statistics
(signature)
District Number7k_53 Place Fort Edward,New York
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 3 (0 1)19 Place of Disposition Shaaray Tefila
W ^� (address)
O -FC-Lt-e:1-4 4512
I (section) lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises (fl/f^c- ('t'Q� k�
Z J (please print
W
Signature 7��/v. Q ,Oc2, -�,-�r' Title ��Jam! .
t%� (over)
DOH-1555 (02/2004)