Bain, Tonya NEW YORK STATE DEPARTMENT OF HEAL/H git 4 -A C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tonya Marie Bain Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 12,2017 45 War or Dates n/a
. Place of Death Hospital, Institution or
Z City, Town or Village City of Glens Falls,NY Street Address Glens Falls Hospital
Iii
Manner of Death i 51 Natural Cause [Accident n Homicide n Suicide n Undetermined Pending
VCircumstances Investigation
W Medical Certifier Name Title
a Terry Comeau,Coroner
Address
Lake George,NY
Death Certificate Filed District Number Register Number
City, Town or Village City of Glens Falls,NY 5601 530.
❑Burial Date Cemetery or Crematory
October 16,2017 Pine View Crematory
❑Entombment Address
IN Cremation Quaker Road,Queensbury,New York
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Dat" Point of
Nn Transportation _ Shipment
p by Common De `.
Carrier
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 Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
a Address
Ct
tit'
II
Permission is ((�herebye granted to dispose of the human €mains escribed bove as i , •ted.
Date Issued !�G► Q� Registrar of Vital Statistics _,7iL-C.
!! (signa !-
District Number 5601 Place ity of Glens Falls,NY 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tu Date of Disposition /i Ill in Place of Disposition ne .' �t �
\J �r(
Ill (address)
(J)
0 (section) r (lot number) (grave number)
p ,-Name of Sexton or Person in Charge of Pr ises ,, r J Q141
'IJ
Z �1/ (pl ase print)
Signature di Title iktIM tiViU
(over)
DOH-1555 (02/2004)