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Black, June Nanette NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex June Nanette Black Female Date of Death Age If Veteran of U.S.Armed Forces, 01/29/2020 91 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 46 Waverly Place,Queensbury Town, New York 12804 p Mannerof Death ©Natural Cause Accident Homicide Suicide Undetermined ❑Pending Circumstances Investigation W Medical Certifier Name Title Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 16 ©Burial Date Cemetery,Crematory or Facility Name 02/03/2020 Pine View Cemetery Entombment Address ❑Cremation Queensbury,New York Donation I 0 ❑Removal Date Place Removed and/or and/or Held N Hold Address Transportation Date Point of a by Common Shipment Carrier Destination Disinterment Date Cemetery Address I Fj Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 701443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Finn Making Disposition or to Whom Remains are Shipped,If Other than Above j Address a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/30/2020 Registrar of Vital Statistics Caroline Oififegarde Barber(EfectronicallySigned) (signature) District Number 5657 Ptace Queensbury, New York I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition lace of Disposition W P 2 /�Z `� P P ' 2 /address/ W Seneca 32L (section) (lot number) (grave number) Name of Sexto Person in Charge of P mises j Z /p se print) IU Signature k t 2, Title DOH-1555(07/18)p 1 of 2 I Public HeaM Law Sec. 4145(2b) 010364 Receipt Human remains of — .`t� �_ t,„ c. 1�— delivered on - , 20 ` Pine View CemeteI}j Represen ng the 6neral home named on b al rmit Official Funeral Directors Reg.or License# i f I i i i