Heaney, Deanna NEW YORK STATE DEPARTMENT OF HEALTH
" Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deanna Winchell Heaney Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 16, 2011 32 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Kingsbury Street Address
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
0John Stoutenberg MD, M.D. Dr.
Address
102 Park St. Glens Falls, NY 12801
Deat ertificate Filed District Number Register Number
City, own )r Village Ki h T5 bu i 5 r1 1,3.- 1 Co
®Burial Date Cemetery or Crematory
December 20, 2011 Pine View Cemetery
❑Entombment Address
['Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
o and/or Address
E Hold Pine View Cemetery
0 Date Point of
d ❑ Transportation Shipment
O by Common Destination
CI` Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
F; Remains are Shipped, If Other than Above
2 Address
re
W'
C' Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued /Q- /y- 40// Registrar of Vital Statistics . !T
(signature)
District Number 576,4_ Place s- PC);
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
uj Date of Disposition 1 2/20/1 1 Place of Disposition Pine View Cemetery
W (address)
0' Oneida 69 & 88 3
W (section) (lot number) (grave number)
O Name of Sexton or Person i Charge of Premises M i rhaP1 GPnier
(please print)
W Signature 4d". Title Superintendent
(over)
I-1555 (02/2004)