Farnan, Helen NE YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Helen S. Farnan ; Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 17, 2011 1 85 1 War or Dates No
r.. Place of Death j Hospital, Institution or
°Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death Natural Cause X Accident I 1 Homicide Suicide Undetermined Pending
Iii Circumstances Investigation
u, Medical Certifier Name Title
William Tedesco Dr.
Address
v,3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed 1 District Number Reg' to 7Aber
City, Town or Village Glens Falls 5601
orCrematory
�Burial Date Cemetery
September 24, 2011 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
WTransportation Shipment
p by Common Destination
Carrier
Disinterment
Date j Cemetery Address
Reinterment Date Cemetery Address
J Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
� Remains are Shipped, If Other than Above
2 Address
tti
O Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 9 12 @ f i i Registrar of Vital Statistics C.,0 cA.A4\2,... 1.&)
(signat e)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 9/24/2011 Place of Disposition Pine View Cemetery
W (address)
N Mohican 56A 4
rt (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises Michael Genier
Z (please print)
Signature q6..u.il-0.....P91 ^' Title Superintendent
(over)
DOH-1555(02/2004)