Dennis, Lanthe nEW Y'ORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
lanthe Y Dennis Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/16/2013 99 years War or Dates
p• Place of Death Hospital, Institution or
• City, Tow i xx Glens Falls Street Address 33 Laxm tnn Ave
0 Manner of Deatha Natural Cause Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
P Robert Beaty M
Address
100 Broad Street Plaza Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
CEity, Towbe/il xx fiert Fans 5Fin1 159
trial Date Address Cemetery or Crematory
Entombment 04/20/201.3 Pine View Cemetery
['Cremation Oueensbury, NY 12804
Date Place Removed
❑Removal and/or Held
• anHold Address
U)
d/or
0 Date Point of
61 Q Transportation Shipment
Es by Common Destination
Carrier
E Disinterment Date Cemetery Address
Q 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
Remains are Shipped, If Other than Above
2 Address
l
f
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/17/2013 Registrar of Vital Statistics Wx• U}-ti"
(si ature)
District Number Place / )V U
5601 Glens Falls
Loi I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p 4/20/13 p Pine View Cemetery
Date of Disposition Place of Disposition
'a (address)
in
til Hudson Sec. 1 8 B 2
CC (section) (lot number) (grave number)
Name of n or Person in Charge of Premises Se
,�Q Connie L. Goedert
Zl_' 1 (please print)
SignatureLa �14iao` -_. ( Title Superintendent
r
(over)
DOH-1555 (02/2004)