Tonnesen, Una II Ili
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Una B Tonnesen Female
Date of Death Age j If Veteran of U.S. Armed Forces,
9/22/2018 98 War or Dates
t— Place of Death , Hospital, Institution or
Z City, Town or Village Moreau I Street Address Home Of The Good Shepard
p Manner of Death C Natural Cause n Accident Homicide Suicide n Undetermined Pending
LU Circumstances Investigation
W Medical Certifier Name Title
O Danushan Soonabalen,MD
Address
161 Carey Road,Queensbury,NY
Death Certificate Filed ; District Number _ Register Cumber
City, Town or Village Moreau `) >>o 21 i 7
❑Burial Date Cemetery or Crematory
September 25, 2018 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or —
Address
E Hold
N
O Date Point of
N 'Transportation Shipment
a by Common Destination
Carrier
I I Disinterment
Date Cemetery Address
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
I— Remains are Shipped, If Other than Above
2 Address
W
a
Permission is hereby granted to dispose of the human re ' descri. . a ve as indicated.
Date Issued 9 lexpo 1 Registrar of Vital Statistics 1C'° ( ii
LL (si nature)
District Number Place ` 'Moreau f 4 ,D?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 9 -11(3 Place of Disposition f'a,U-� eart6--
2 (address)
LU
CO
CC
(section) n (lot number) c (grave number)
p Name of Sexton or Person in Charge of Premises G At* tr Job
z (pie se print)
W Signature St4 Title .
(over)
DOH-1555(02/2004)