Tennant, Dianna NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dianna Lynn Tennant Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/21/2013 57 years War or Dates
: Place of Death Hospital, Institution or
W City, TowxxxVil• XX Glens Falls Street Address park st glens falls, n y 12801
a Manner of Death J Natural Cause 0 Accident O Homicide O Suicide O Undetermined O Pending
MtCircumstances investigation
ut Medical Certifier Name Title
0 Ageel A. Gillani M D
Address
102 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Towwxxjf/il Glens Falls 5601 312
:: [RQririal Date Cemetery or Crematory
❑Entombment 07/24/2013 Pine View Cemetery
Address
i'OCremation Queensbury, NY 12804
Date Place Removed
2❑Removal and/or Held
and/or Address
t= Hold
'I)
0 Date Point of
5❑Transportation Shipment
C by Common Destination
Carrier
O Disinterment Date Cemetery Address .
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804 •
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
'a Address
.
Ili
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/23/2013 Registrar of Vital Statistics L .7 CA" "U' . L )
(sign
District Number 5601 Place Glens Falls) N Y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
7/24/13 Pine View Cemetery
of Disposition Place of Disposition
(address)
1 Unadilla 51 D 3
CC (section) (lot number) (grave number)
CI Name of Se ton or Person in Charge of Premises Connie L. Goedert
Ziii (please print)
Signature Title Superintendent
(over)
DOH-1555 (02/2004)